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
- Activate stroke pathway; CT/CTA rapidly; check eligibility and deliver lysis when indicated.
- If LVO and eligible → thrombectomy; manage BP and glucose targets.
- Start secondary prevention and rehabilitation planning; screen for AF with telemetry.
Clinical Synopsis & Reasoning
Rapid recognition with last-known-well time is critical. Noncontrast CT excludes hemorrhage; CTA detects large vessel occlusion. Offer IV thrombolysis within established windows when eligible, and consider mechanical thrombectomy up to 24 h in selected LVO cases; manage BP and glucose tightly.
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 |
|---|
| Noncontrast head CT (STAT) ± CTA/CTP | Diagnosis | Exclude hemorrhage; identify LVO | — |
| Glucose, coagulation tests, and pregnancy test (selected) | Safety | Rule out mimics/contraindications | — |
| NIHSS documentation | Severity | Guides triage and outcomes | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| tPA/TNK eligibility within window | Functional outcome | Rapid thrombolysis after CT |
| Large vessel occlusion on CTA | Salvageable brain | Thrombectomy up to 24 h (DAWN/DEFUSE 3 criteria) |
| BP >185/110 (thrombolysis candidates) | ICH risk | Labetalol/nicardipine to target |
| Anticoagulant use or DOAC timing | Bleeding risk | Reversal/levels if available |
| Posterior circulation symptoms | Missed diagnosis risk | Lower threshold for imaging and thrombectomy |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Alteplase 0.9 mg/kg (max 90 mg) IV within window or Tenecteplase 0.25 mg/kg (selected) | Thrombolysis | Minutes | Reperfusion therapy | Strict inclusion/exclusion criteria |
| BP control: <185/110 for thrombolysis candidates; permissive up to 220/120 if no lysis | Antihypertensives | Minutes | Labetalol/Nicardipine | Frequent monitoring |
| Antiplatelet therapy (after 24 h post-lysis or if no lysis) | Secondary prevention | Hours | Aspirin ± short DAPT in minor stroke/TIA | — |
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 — Link