Acute Stroke Management
Acute Ischemic Stroke Management
What Do You Need to Know?
- 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)
🚩 Don’t Miss — Test-Day Priorities
- 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).
🔍 Buzzwords & Pathognomonic FindingsReperfusion 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 |
|---|---|---|
| 1a | Level of Consciousness | 0–3 |
| 1b | LOC Questions (month, age) | 0–2 |
| 1c | LOC Commands (open/close eyes, grip/release) | 0–2 |
| 2 | Best Gaze | 0–2 |
| 3 | Visual Fields | 0–3 |
| 4 | Facial Palsy | 0–3 |
| 5a/5b | Motor Arm (L/R) — hold 90° for 10 sec | 0–4 each |
| 6a/6b | Motor Leg (L/R) — hold 30° for 5 sec | 0–4 each |
| 7 | Limb Ataxia | 0–2 |
| 8 | Sensory | 0–2 |
| 9 | Best Language | 0–3 |
| 10 | Dysarthria | 0–2 |
| 11 | Extinction/Inattention | 0–2 |
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.
IV Thrombolysis (tPA / Alteplase)
Time Windows & Evidence
- <3 hours (NINDS, 1995): FDA-approved. 16% absolute increase in favorable outcomes. NNT ~8. Standard of care — no informed consent required
- 3–4.5 hours (ECASS III, 2008): AHA/ASA recommended (Class I) but NOT FDA-approved. Additional exclusions: age >80, NIHSS >25, oral anticoagulant use, history of BOTH diabetes AND prior stroke
- Up to 9 hours (EXTEND trial): Showed benefit using perfusion imaging selection (penumbral mismatch), but with increased risk of symptomatic ICH
- Wake-up strokes (WAKE-UP trial): DWI-FLAIR mismatch (DWI+ / FLAIR−) identifies patients with unknown onset who benefit from tPA
Dosing
- 0.9 mg/kg (max 90 mg total)
- 10% as IV bolus over 1 minute, remaining 90% infused over 60 minutes
Absolute Exclusion Criteria (<3 Hours)
- Significant head trauma or prior stroke in past 3 months
- Symptoms suggestive of SAH
- Arterial puncture at noncompressible site within 7 days
- History of previous intracranial hemorrhage
- Intracranial neoplasm, AVM, or aneurysm
- Recent intracranial or intraspinal surgery
- BP >185/110 that cannot be lowered
- Active internal bleeding
- Platelet count <100,000
- Heparin within 48 hours with elevated aPTT
- INR >1.7 or PT >15 seconds
- DOAC use with elevated lab tests
- Blood glucose <50 mg/dL
- CT showing multilobar infarction (>1/3 hemisphere)
Relative Contraindications
- Minor or rapidly improving symptoms
- Pregnancy
- Seizure at onset with postictal neurological impairments
- Major surgery or serious trauma within 14 days
- Recent GI or GU hemorrhage (within 21 days)
Orolingual Angioedema
- Occurs in 1.3–5.1% of patients; increased risk with ACE inhibitors
- Contralateral to the ischemic hemisphere
- Management: stop infusion if severe, epinephrine, antihistamines, airway management
💎 Board Pearl
Alteplase 0.9 mg/kg or tenecteplase 0.25 mg/kg (max 25 mg) are both guideline-endorsed IV thrombolytics within 4.5 h for eligible disabling AIS per the AHA/ASA 2026 update. Alteplase is FDA-approved <3 h (NINDS); the 3–4.5 h window (ECASS III) is AHA Class I but not FDA-approved.
Mechanical Thrombectomy
Five landmark trials in 2015 (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT) all proved benefit of endovascular thrombectomy with stent retrievers for LVO in the anterior circulation.
Standard Criteria (0–6 Hours)
- Prestroke mRS 0–1 (functionally independent)
- Causative occlusion of ICA or proximal MCA (M1)
- NIHSS ≥6
- ASPECTS ≥6 on NCCT is the classic early-window trial pattern; selected ASPECTS 3–5 / large-core patients can also benefit per SELECT2 / ANGEL-ASPECT / RESCUE-Japan LIMIT
- Groin puncture achievable within 6 hours of onset
- Does NOT replace IV tPA — give tPA first if eligible (“bridging therapy”)
Extended Windows (6–24 Hours)
- DAWN trial (2018): Thrombectomy up to 24 hours — clinical-imaging mismatch selection (high NIHSS with small infarct core on CTP/DWI). NNT ~2.8. Stopped early for overwhelming efficacy
- DEFUSE 3 trial (2018): Thrombectomy 6–16 hours — perfusion mismatch selection (core <70 mL, mismatch ratio ≥1.8, mismatch volume ≥15 mL)
- Both trials proved “tissue-based” rather than “time-based” selection — advanced imaging (CTP or MRI perfusion) is REQUIRED in extended windows
Key Terms
- ASPECTS: 10-point CT score for MCA territory. Subtract 1 point per region with early ischemic changes. ≥6 = classic early-window EVT candidate; selected ASPECTS 3–5 (large core) also benefit per SELECT2 / ANGEL-ASPECT / RESCUE-Japan LIMIT depending on LVO site, age, disability, imaging, and protocol.
- mTICI scale: 0 = no perfusion; 2a = <50% reperfusion; 2b = ≥50% reperfusion; 2c = near-complete with slow flow; 3 = complete perfusion. Goal = TICI 2b/2c/3
💎 Board Pearl
Thrombectomy = LVO (ICA or M1 MCA, selected M2). ASPECTS ≥6 + NIHSS ≥6 within 6 h is the classic pattern, but selected large-core patients (ASPECTS 3–5) also benefit per SELECT2 / ANGEL-ASPECT / RESCUE-Japan LIMIT. DAWN extends to 24 h and DEFUSE 3 to 16 h with mismatch-based selection.
Blood Pressure Management
| Scenario | BP Target |
|---|---|
| Not a tPA candidate | Permissive hypertension up to 220/120; treat only if above |
| Before tPA | Must lower to <185/110 before administering |
| After tPA (first 24h) | Maintain <180/105 |
| Post-thrombectomy | Maintain ≤180/105 × 24 h; avoid routine intensive SBP <140 after EVT (AHA/ASA 2026) — individualize with the neurointerventional team |
Agents
- Labetalol: 10–20 mg IV bolus, may repeat; avoid in asthma/bradycardia
- Nicardipine: 5 mg/hr IV infusion, titrate by 2.5 mg/hr q5–15 min (max 15 mg/hr) — preferred for precise BP control
- Clevidipine: Ultra-short-acting CCB; rapid onset/offset
💎 Board Pearl
BP >185/110 is a CONTRAINDICATION to tPA — lower it first. After tPA, maintain <180/105 for 24h. In non-tPA patients, do NOT lower BP aggressively — the penumbra depends on pressure-dependent collateral perfusion.
Complications of Acute Ischemic Stroke
Hemorrhagic Transformation
- Symptomatic ICH: ~6% with tPA vs ~0.6% placebo
- Risk factors: Large infarct, high NIHSS, hyperglycemia, advanced age, elevated BP
- If patient deteriorates during/after tPA:
- Stop tPA immediately
- Stat NCCT head
- Check fibrinogen → give cryoprecipitate (10 units) if fibrinogen <200 mg/dL
- Consider tranexamic acid or aminocaproic acid
Cerebral Edema & Malignant MCA Syndrome
- Edema peaks at 3–5 days after onset
- Younger patients (<60) are at higher risk — less atrophy, less room for swelling
- Decompressive hemicraniectomy (DECIMAL, DESTINY, HAMLET trials): Indicated in patients <60 years within 48 hours. Reduces mortality from ~78% to ~29%, but may increase survival with moderate-to-severe disability (mRS 4) — requires goals-of-care discussion
- Medical management: HOB 30°, osmotic therapy (mannitol, hypertonic saline), avoid hyperthermia and hyperglycemia
Other Complications
- Seizures: Early seizures in ~5%; more common with cortical involvement. Treat acute seizures but do NOT use prophylactic antiepileptics
- DVT/PE: Start IPC devices immediately; pharmacologic prophylaxis after 24–48h if no hemorrhage
- Aspiration pneumonia: Leading cause of subacute death — swallow evaluation before any oral intake
💎 Board Pearl
If deterioration during tPA: stop infusion, stat CT, check fibrinogen, give cryoprecipitate if <200. Do NOT use prophylactic antiepileptics after stroke. Decompressive hemicraniectomy in patients <60 reduces mortality but increases survival with disability.
Supportive Care
- Aspirin 160–325 mg within 24–48 hours for ALL ischemic stroke patients. If tPA given, wait 24 hours before starting (confirm no ICH on follow-up imaging)
- Swallow evaluation: NPO until bedside screen completed — aspiration pneumonia is the leading cause of post-stroke mortality
- DVT prophylaxis: IPC devices immediately; subcutaneous heparin/LMWH after 24–48 hours (IPC preferred over compression stockings — CLOTS 3 trial)
- Glucose: Target 140–180 mg/dL. Hyperglycemia worsens outcomes; treat hypoglycemia aggressively
- Temperature: Treat fever (≥38°C) aggressively — independent predictor of worse outcomes
- Statin: High-intensity statin for atherosclerotic stroke regardless of LDL; do NOT stop statins in the acute phase (rebound effect)
- Rehabilitation: Initiate early once medically stable (PT, OT, speech)
💎 Board Pearl
Aspirin within 24–48h for all ischemic strokes (wait 24h if tPA given). Swallow eval before oral intake. Do NOT stop statins acutely.
References
- National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581-1587.
- Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke (ECASS III). N Engl J Med. 2008;359(13):1317-1329.
- Ma H, Campbell BCV, Parsons MW, et al. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke (EXTEND). N Engl J Med. 2019;380(19):1795-1803.
- Thomalla G, Simonsen CZ, Boutitie F, et al. MRI-guided thrombolysis for stroke with unknown time of onset (WAKE-UP). N Engl J Med. 2018;379(7):611-622.
- Berkhemer OA, Fransen PSS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke (MR CLEAN). N Engl J Med. 2015;372(1):11-20.
- Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct (DAWN). N Engl J Med. 2018;378(1):11-21.
- Albers GW, Marks MP, Kemp S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging (DEFUSE 3). N Engl J Med. 2018;378(8):708-718.
- Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis (DECIMAL, DESTINY, HAMLET). Lancet Neurol. 2007;6(3):215-222.
- Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update. Stroke. 2019;50(12):e344-e418.
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