Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or reperfusion when indicated; document follow‑up and patient education.
Algorithm
- Pre‑arrival activation; record last‑known‑well, NIHSS on arrival; POC glucose.
- Immediate non‑contrast CT; if no hemorrhage and eligible → IV alteplase ≤4.5 h.
- Parallel CTA for LVO; activate thrombectomy team when LVO suspected.
- Extended window (6–24 h) → select with perfusion imaging per DAWN/DEFUSE‑3 criteria; proceed to MT when eligible.
- Manage BP (pre‑tPA <185/110; post‑tPA ≤180/105); admit to ICU/stroke unit for 24 h monitoring.
- Repeat imaging at 24 h; start antithrombotic per protocol; secondary prevention workup (AFib, carotid, lipids).
Clinical Synopsis & Reasoning
Rapid triage by last‑known‑well and stroke severity, non‑contrast CT to exclude hemorrhage, CTA for LVO, IV alteplase within 4.5 h when eligible, and mechanical thrombectomy up to 24 h in selected patients; strict BP and neuro monitoring after reperfusion.
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 | Exclude hemorrhage | No bleed in AIS | Do not delay if window narrow |
| CTA head/neck ± CTP/MR perfusion | LVO selection | Target occlusion/penumbra | For extended‑window MT selection |
| Glucose, INR/platelets | Eligibility checks | Abnormalities may preclude lytics | Point‑of‑care when possible |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Alteplase (tPA) 0.9 mg/kg (max 90 mg) | Thrombolytic | Minutes | IV thrombolysis ≤4.5 h (10% bolus, rest over 60 min) | Standard contraindications; post‑tPA BP ≤180/105 |
| Nicardipine/clevidipine infusion | Antihypertensive | Minutes | Pre/post‑reperfusion BP control | Avoid hypotension |
| Aspirin | Antiplatelet | Hours | Start 24 h post‑tPA if no bleed | Earlier if no tPA and no hemorrhage |
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
- 2019 AHA/ASA Guideline Update for the Early Management of AIS — Link
- AHA/ASA 2019 AIS Slide Deck (Door‑to‑Needle/Thrombectomy) — Link
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