Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
Acute focal deficits with precise time of onset demand immediate differentiation of ischemia from hemorrhage. Obtain non‑contrast CT to exclude bleed and assess for early ischemic changes; check glucose and BP, and screen for thrombolysis contraindications. Use vessel/perfusion imaging when available to define large‑vessel occlusion and salvageable penumbra. Risk‑benefit assessment should consider pre‑morbid function, anticoagulant exposure, and imaging core size to guide IV thrombolysis and thrombectomy decisions.
Treatment Strategy & Disposition
For eligible patients within the window, administer IV thrombolysis after BP control (≤185/110 mmHg) and proceed to mechanical thrombectomy for LVO per imaging criteria. Maintain normoxia, euglycemia, and normothermia; avoid routine hypotonic fluids. Initiate antiplatelet therapy after post‑thrombolysis imaging excludes hemorrhagic transformation; manage atrial fibrillation with anticoagulation on a delayed schedule based on infarct size. Early dysphagia screening, DVT prophylaxis, and mobilization reduce complications. Admit to a stroke unit/ICU depending on severity and need for neuro‑monitoring and BP titration.
Epidemiology / Risk Factors
- Hypertension, AF, atherosclerosis; prior stroke/TIA
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CT Head (NC) | Hemorrhage exclusion | Acute blood | First-line |
| Glucose (POC) | Exclude hypoglycemia | Low | Treat promptly |
| MRI Brain (selected) | Ischemia/structural | Diffusion restriction |
IV Thrombolysis Quick Screen
| Item | Threshold or Rule |
|---|---|
| CT head | No hemorrhage or large established infarct |
| Time | ≤4.5 h from last known well |
| BP prior to bolus | ≤185/110 mmHg with treatment if needed |
| Glucose | Correct severe hypo- or hyperglycemia |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Alteplase (IV) | Plasminogen activation | Minutes | Within eligibility window | ICH risk; strict contraindications; ED use |
| Dual antiplatelet (short course) | ASA + clopidogrel | Hours | Minor stroke/TIA early period | Bleeding; ED use |
| Aspirin (after lysis window) | COX-1 inhibition | Hours | Secondary prevention | Bleeding; ED use |
| Tenecteplase (IV bolus) | Plasminogen activation | Minutes | Alternative to alteplase in select settings | ICH risk; ED use |
| BP control individualized | See HTN agents | Minutes | Pre/post-reperfusion | Hypotension risk; ED use |
Prognosis / Complications
- Outcome tied to time-to-reperfusion; aspiration/DVT risks
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
Notes
Use institutional protocol for alteplase vs tenecteplase. Thrombectomy decisions rely on vessel imaging and perfusion mismatch in extended windows.