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 |
Reperfusion Pathways
| Scenario | Action | Notes |
|---|---|---|
| Within IV tPA/tenecteplase window | Give thrombolytic | Respect contraindications |
| Large-vessel occlusion | Mechanical thrombectomy | Imaging selection guides extended window |
| Outside reperfusion | Best medical therapy | BP control, antiplatelets, VTE prophylaxis |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Alteplase/Tenecteplase | Fibrinolysis | Minutes | Within eligibility window | ICH risk; strict contraindications |
| Aspirin (after lysis window) | COX-1 inhibition | Hours | Secondary prevention | 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.
Notes
Check glucose and temperature; avoid hypotension. Consider posterior-circulation LVO even with mild NIHSS if disabling symptoms.