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 |
tPA Absolute Contraindications (Examples)
| Contraindication | Notes |
|---|---|
| Intracranial hemorrhage on imaging | |
| BP >185/110 uncontrolled | |
| Platelets <100k or INR >1.7 | Anticoagulant use |
| Recent major surgery/head trauma (<3 mo) | |
| Prior intracranial hemorrhage |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Alteplase (IV) | Plasminogen activation | Minutes | Within eligibility window | ICH risk; strict contraindications |
| Tenecteplase (IV bolus) | Plasminogen activation | Minutes | Alternative to alteplase in select settings | ICH risk |
| Aspirin (after lysis window) | COX-1 inhibition | Hours | Secondary prevention | Bleeding |
| BP control individualized | See HTN agents | Minutes | Pre/post-reperfusion | Hypotension risk |
| Dual antiplatelet (short course) | ASA + clopidogrel | Hours | Minor stroke/TIA early period | Bleeding |
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.
Pathway Notes
Keep door‑to‑needle <60 minutes. Manage temperature and glucose. Coordinate transfer for thrombectomy when needed.
References
- AHA/ASA Stroke Guidelines — Link