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12 notes available
1 Last Minute Review 2 Cerebrovascular Anatomy 3 Stroke Syndromes 4 Acute Stroke Management 5 Stroke Workup 6 Secondary Prevention 7 Intracerebral Hemorrhage 8 SAH & Aneurysms 9 SDH & EDH 10 Venous Thrombosis 11 Vascular Malformations 12 Special Vascular Topics
Clinical › Vascular

Acute Stroke Management

Acute Ischemic Stroke Management

What You'll Learn

  • Initial evaluation, stroke code workflow, and stroke mimics
  • NIHSS scoring categories, interpretation, and limitations
  • IV tPA time windows and landmark trials (NINDS, ECASS III, EXTEND, WAKE-UP)
  • tPA dosing, exclusion criteria, and orolingual angioedema
  • Mechanical thrombectomy criteria and extended windows (DAWN, DEFUSE 3)
  • ASPECTS scoring and TICI grading
  • Blood pressure management targets before and after reperfusion therapy
  • Complications: hemorrhagic transformation, malignant MCA syndrome, seizures, DVT, aspiration
  • Supportive care essentials (aspirin timing, swallow eval, glucose, statins)
HighYield Pearls
  • Alteplase 0.9 mg/kg (max 90 mg) ≤4.5 h from LKW: 10% bolus + 90% over 60 min; BP must be ≤185/110 before bolus and ≤180/105 × 24 h after.
  • Tenecteplase 0.25 mg/kg IV bolus (max 25 mg) or alteplase 0.9 mg/kg: both are guideline-endorsed IV thrombolytic options within 4.5 h for eligible disabling AIS (AHA/ASA 2026) — TNK is single-bolus, advantageous for LVO transfers.
  • Thrombectomy 0–6 h: ICA / M1 (and selected M2) LVO, NIHSS ≥6; ASPECTS ≥6 is the classic early-window trial pattern (HERMES). Selected large-core patients (ASPECTS 3–5 or core-volume criteria) can also benefit out to 24 h per SELECT2 / ANGEL-ASPECT / RESCUE-Japan LIMIT. Goal TICI 2b–3; door-to-puncture <90 min in-house, <60 min if transferred.
  • Extended window 6–24 h: DAWN (clinical-core mismatch, NIHSS ≥10, small core) or DEFUSE 3 6–16 h (perfusion mismatch, core ≤70 mL, mismatch ratio ≥1.8).
  • Large-core thrombectomy: SELECT-2 / ANGEL-ASPECT / RESCUE-Japan LIMIT — benefit for ASPECTS 3–5 or core >50 mL out to 24 h.
  • Basilar occlusion: ATTENTION / BAOCHE support thrombectomy up to 24 h — don’t use anterior-circulation criteria.
  • Wake-up / unknown LKW: WAKE-UP trial — DWI-FLAIR mismatch → eligible for IV tPA.
  • Post-tPA monitoring: NIHSS + BP q15 min × 2 h, q30 min × 6 h, q1 h × 16 h; NO antiplatelet / anticoag × 24 h until repeat CT.
  • Orolingual angioedema (1–5%, ACE-I users): stop tPA, secure airway, antihistamine + steroids + epinephrine if airway threatened.
  • Symptomatic ICH post-tPA/TNK: stop infusion → emergent CT + CBC / PT / PTT / INR / fibrinogen / type & cross → cryoprecipitate (often 10 U initial) to maintain fibrinogen ≥150–200 mg/dL ± TXA or aminocaproic acid; reserve platelets for thrombocytopenia or specific antiplatelet/procedural scenarios; neurosurgery consult.
  • DAPT (CHANCE / POINT / CHANCE-2): minor stroke NIHSS ≤3 or high-risk TIA ABCD2 ≥4 → clopidogrel 300 mg load + ASA 81 mg × 21–30 d then mono; CHANCE-2 → ticagrelor + ASA for CYP2C19 LOF.
  • BP without reperfusion: permissive HTN up to 220/120 unless end-organ injury (dissection, MI, AKI, LVH strain).
  • Malignant MCA (<60 y): hemicraniectomy within 24–48 h reduces mortality — don’t wait for herniation.
  • Cerebellar infarct ≥3 cm with mass effect / decline: sub-occipital decompressive craniectomy.
  • Dysphagia screen BEFORE any PO (meds, water, food); statin started early; glucose target 140–180; DVT ppx with UFH/LMWH day 1 (delay 24 h after tPA).
🔍 Quick ReferenceReperfusion criteria · Imaging / triage · BP / supportive
Reperfusion criteria / drugs
  • “0.9 mg/kg, max 90 mg, 10% bolus + 90% over 60 min” → alteplase dosing
  • “0.25 mg/kg single bolus, max 25 mg” → tenecteplase (AHA/ASA 2026 guideline-endorsed alternative to alteplase ≤4.5 h)
  • “Clinical-core mismatch, NIHSS ≥10, small core, 6–24 h” → DAWN → thrombectomy
  • “Perfusion mismatch ratio ≥1.8, core ≤70 mL, 6–16 h” → DEFUSE 3 → thrombectomy
  • “ASPECTS 3–5 / core >50 mL benefit” → SELECT-2 · ANGEL-ASPECT (large-core MT)
  • “Minor stroke NIHSS ≤3 / high-risk TIA ABCD2 ≥4” → CHANCE / POINT DAPT (clopi + ASA × 21–30 d)
  • “CYP2C19 loss-of-function carrier” → CHANCE-2 → ticagrelor + ASA
  • “Basilar occlusion ≤24 h” → ATTENTION / BAOCHE → thrombectomy
Imaging / triage
  • “Hyperdense MCA / MCA dot sign” → proximal LVO → CTA + activate MT pathway
  • “Insular ribbon / obscured lentiform” → early cytotoxic edema (MCA)
  • “ASPECTS ≥6 in <6 h window” → HERMES → thrombectomy candidate (classic early-window pattern; large-core ASPECTS 3–5 also eligible per SELECT2 / ANGEL-ASPECT / RESCUE-Japan LIMIT)
  • “DWI-FLAIR mismatch in unknown-onset / wake-up” → WAKE-UP → IV tPA eligible
  • “TICI 2b–3” → successful reperfusion goal
  • “Door-to-CT <25 min, door-to-needle <60 min, door-to-puncture <90 min” → quality benchmarks
BP / supportive / pitfalls
  • “Pre-tPA ≤185/110, post-tPA ≤180/105 × 24 h” → labetalol / nicardipine / clevidipine
  • “No reperfusion → permissive HTN up to 220/120” → do NOT lower unless end-organ injury
  • “Orolingual edema on ACE-inhibitor after tPA” → stop tPA, antihistamine + steroids + epi, airway
  • “Symptomatic ICH post-tPA (PH-2, mass effect)” → stop infusion, cryoprecipitate ± TXA / aminocaproic acid, platelets only if thrombocytopenia or specific antiplatelet/procedural indication, neurosurgery
  • “Malignant MCA, age <60, 24–48 h” → decompressive hemicraniectomy
  • “Cerebellar infarct ≥3 cm + mass effect / decline” → sub-occipital craniectomy
  • “Dysphagia screen failed” → NPO + IV fluids + SLP eval (prevents aspiration PNA)
  • “Glucose target 140–180, avoid hypoglycemia” → supportive care; high-intensity statin ASAP; DVT ppx day 1 (24 h delay after tPA)
Initial Evaluation & Stabilization
  • ABCs first → then establish Last Known Well (LKW) time — the single most critical piece of information for treatment decisions
  • “Onset time” = when the patient was LAST SEEN NORMAL — NOT when found with deficits
  • Wake-up stroke: LKW = when last seen normal before sleep

Stroke Code Rapid Assessment

  • Activate stroke code immediately upon suspicion
  • Perform NIHSS at bedside
  • Stat NCCT head — rule out hemorrhage before tPA
  • Establish IV access, draw labs, obtain blood glucose
  • Goal: door-to-CT <25 min; door-to-needle <60 min

Stroke Mimics

  • Seizure with Todd’s paralysis: Witnessed seizure activity; resolves within 24 hours
  • Hypoglycemia: Check glucose immediately; focal deficits resolve with correction
  • Complicated migraine: Gradual onset “marching” symptoms; headache follows
  • Conversion disorder: Inconsistent exam, doesn’t follow vascular territory; Hoover’s sign
💎 Board Pearl

The ONLY tests required before giving tPA are NCCT head (rule out hemorrhage) and blood glucose. Do NOT delay tPA for any other lab results unless clinical suspicion of coagulopathy.

Early CT Signs of Ischemic Stroke

  • Hyperdense MCA sign: hyperdensity (~≥43 HU) of the proximal M1 segment on NCCT = acute intraluminal thrombus and predicts a proximal LVO. Trigger CTA and mobilize the thrombectomy pathway.
  • MCA “dot” sign: same finding in an M2/M3 branch within the Sylvian fissure.
  • Insular ribbon sign: loss of the cortical-white matter differentiation at the insular cortex (early cytotoxic edema in MCA territory).
  • Obscured lentiform nucleus: earliest sign of striatal infarction (lenticulostriate territory).
  • Cortical sulcal effacement from early cytotoxic edema.
  • ASPECTS score (0–10) quantifies early ischemic changes across 10 MCA-territory regions; ASPECTS ≥6 qualifies for thrombectomy in the 0–6 h window per HERMES.
💎 Board Pearl

A focal hyperdensity in the M1 segment on the screening NCCT is the single most actionable early sign — it predicts LVO and a thrombectomy candidate. Pseudo-hyperdense MCA can occur in dehydration, polycythemia, or calcified atheroma — correlate with CTA.

NIH Stroke Scale (NIHSS)

Standardized stroke severity scale. Total range: 0–42.

Item Category Score
1aLevel of Consciousness0–3
1bLOC Questions (month, age)0–2
1cLOC Commands (open/close eyes, grip/release)0–2
2Best Gaze0–2
3Visual Fields0–3
4Facial Palsy0–3
5a/5bMotor Arm (L/R) — hold 90° for 10 sec0–4 each
6a/6bMotor Leg (L/R) — hold 30° for 5 sec0–4 each
7Limb Ataxia0–2
8Sensory0–2
9Best Language0–3
10Dysarthria0–2
11Extinction/Inattention0–2

Score Interpretation

  • 0: No stroke symptoms
  • 1–4: Minor stroke
  • 5–15: Moderate stroke
  • 16–20: Moderate-to-severe stroke
  • 21–42: Severe stroke
  • NIHSS ≥6 is generally the threshold for thrombectomy eligibility
💎 Board Pearl

NIHSS is biased toward anterior/left hemisphere strokes. It heavily weights language and right-sided motor deficits. Posterior circulation strokes (vertigo, ataxia, diplopia) may score very low despite life-threatening deficits.

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