Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Rapid stroke recognition; CT to exclude hemorrhage; check glucose.
- If within 4.5 h and eligible → IV thrombolysis; manage BP to targets.
- Assess for LVO and EVT window (up to 24 h with perfusion selection).
- Begin secondary prevention (antiplatelet, statin) and stroke unit care; swallow screen; early rehab.
Clinical Synopsis & Reasoning
For eligible patients within 4.5 hours of onset, offer IV thrombolysis. Evaluate for large-vessel occlusion and consider endovascular thrombectomy within 6 hours, and up to 24 hours based on perfusion imaging selection. Maintain BP control (≤185/110 for lysis; permissive hypertension otherwise) and start secondary prevention.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Non-contrast head CT (first) | Exclude hemorrhage | No bleed | Door-to-CT within 20 min |
| CTA head/neck ± CTP/MRI | LVO identification/selection | Targets for EVT | Use perfusion mismatch for extended windows |
| Glucose, INR/platelets | Safety checks | Hypoglycemia, coagulopathy | Do not delay imaging |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| LVO within EVT window | Large salvageable penumbra | Immediate EVT pathway |
| BP >185/110 when thrombolysis planned | ICH risk | Rapid BP control to targets |
| Unknown onset but DWI-FLAIR mismatch | Possible thrombolysis candidate | Advanced imaging-based lysis at experienced centers |
| Anticoagulated patients | Bleeding risk | Reversal/avoid lysis depending on agent/levels |
| Posterior circulation symptoms with coma | High mortality | Early imaging and EVT consideration |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Alteplase 0.9 mg/kg (max 90 mg) within 4.5 h | Thrombolytic | Minutes | Improves outcomes in eligible patients | Contraindications apply |
| Tenecteplase 0.25 mg/kg (max 25 mg) (alternative) | Thrombolytic | Minutes | Consider for LVO prior to EVT (institution dependent) | Evolving evidence/guidelines |
| BP control: Labetalol/Nicardipine/Clevidipine | Antihypertensives | Minutes | Reach ≤185/110 pre-lysis; ≤180/105 post-lysis | Avoid hypotension |
| Aspirin 160–325 mg (if no lysis) or 24 h after lysis | Antiplatelet | Hours | Secondary prevention | Withhold 24 h post-lysis |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- AHA/ASA Stroke Guidelines (IV thrombolysis/EVT) — Link