A last-minute review of high-yield vascular neurology facts for RITE and board exams. Dense tables, no prose — designed for rapid scanning in the final hours before your test.
IV tPA Criteria
Inclusion Criteria
Criterion
Detail
Time window
≤4.5 hours from last known well (LKW)
Age
≥18 years
Diagnosis
Measurable neurological deficit caused by ischemic stroke
CT head
No evidence of hemorrhage
Absolute Exclusion Criteria
Category
Exclusions
Hemorrhage
Any ICH on CT; SAH suspicion
Coagulopathy
Platelets <100k; INR >1.7; aPTT >40s; PT >15s
Heparin
Heparin within 48h with elevated aPTT
DOACs
DOAC within 48h (unless normal drug-specific assay or anti-Xa)
Recent surgery
Major surgery or serious trauma within 14 days
GI/GU bleed
Within 21 days
Arterial puncture
Non-compressible site within 7 days
Prior stroke/head trauma
Within 3 months
BP
>185/110 despite treatment
Glucose
<50 mg/dL
Endocarditis
Infective endocarditis — risk of septic emboli hemorrhage
Was exclusion in ECASS III; now relative per AHA 2019
Diabetes + prior stroke
Combination was excluded in ECASS III; now relative
Dosing & Administration
Parameter
Value
Dose
0.9 mg/kg (max 90 mg)
10% bolus
IV over 1 minute
Remaining 90%
IV infusion over 60 minutes
BP goal post-tPA
<180/105 for 24 hours
No antiplatelets/anticoagulants
For 24 hours post-tPA
Follow-up CT
At 24 hours (before starting antiplatelets)
💎 Board Pearl
Only 2 tests required before giving tPA: NCCT head + blood glucose. Do NOT delay for other labs unless clinical suspicion of coagulopathy. Wake-up stroke with DWI-FLAIR mismatch can receive tPA (WAKE-UP trial). Tenecteplase 0.25 mg/kg (max 25 mg) IV bolus is guideline-endorsed alongside alteplase 0.9 mg/kg within 4.5 h (AHA/ASA 2026).
Mechanical Thrombectomy Criteria
Standard Window (0–6 hours)
Criterion
Requirement
LVO confirmed
ICA, M1, or proximal M2 occlusion on CTA/MRA
NIHSS
≥6
ASPECTS
≥6 on NCCT (classic early-window pattern); selected ASPECTS 3–5 / large-core patients also benefit per SELECT2 / ANGEL-ASPECT / RESCUE-Japan LIMIT
Pre-stroke mRS
0–1
Age
≥18
Extended Window (6–24 hours)
Trial
Window
Key Eligibility
DAWN
6–24 h
Clinical-core mismatch (small infarct, large deficit); NIHSS ≥10; core <21–51 mL (age-dependent)
DEFUSE 3
6–16 h
Perfusion mismatch ratio ≥1.8; ischemic core <70 mL; mismatch volume ≥15 mL
LVO Sites Amenable to Thrombectomy
Vessel
Evidence Level
ICA (intracranial)
Strong — included in all major RCTs
M1 (MCA)
Strong — most common target
Proximal M2
Moderate — included in recent trials
Basilar artery
Moderate — ATTENTION & BAOCHE trials positive
Distal M2, A1, A2
Insufficient — case-by-case basis
Arterial territories — ACA/MCA/PCA supply and the watershed zones behind border-zone infarcts.Modernized from Gray's Anatomy (public domain) · HighYieldNeuro
TICI Reperfusion Grading
Grade
Definition
0
No perfusion
1
Penetration, no distal filling
2a
<50% territory perfused
2b
≥50% territory perfused
2c
Near-complete perfusion with slow flow
3
Complete perfusion
💎 Board Pearl
Thrombectomy is NOT a substitute for tPA. If eligible for both, give tPA immediately and proceed to thrombectomy (bridging therapy). Target: TICI 2b–3. Successful reperfusion = TICI ≥2b. Basilar thrombectomy now supported up to 24 h (ATTENTION trial).
NIHSS Key Components
Item
What It Tests
Max Score
1a
Level of consciousness (alertness)
3
1b
LOC questions (month, age)
2
1c
LOC commands (open/close eyes, grip/release)
2
2
Best gaze (horizontal eye movements)
2
3
Visual fields (confrontation)
3
4
Facial palsy
3
5a/5b
Motor arm L/R (hold 90° sitting / 45° supine for 10 s)
4 each
6a/6b
Motor leg L/R (hold 30° supine for 5 s)
4 each
7
Limb ataxia (finger-nose, heel-shin)
2
8
Sensory (pinprick)
2
9
Best language (aphasia)
3
10
Dysarthria
2
11
Extinction / inattention (neglect)
2
Total: 0–42 | Minor ≤4 | Moderate 5–15 | Moderate-severe 16–20 | Severe ≥21
💎 Board Pearl
NIHSS is left-hemisphere/anterior biased. It heavily weights language (max 5 pts) and right-sided motor (scored equally). Posterior circulation strokes (vertigo, diplopia, ataxia, bilateral weakness) can score near zero despite devastating deficits. A “low NIHSS” does NOT rule out a dangerous stroke.
Stroke Syndromes by Territory
Territory
Vessel
Classic Findings
ACA
A2 segment
Contralateral leg > arm weakness; abulia; urinary incontinence; alien hand (dominant); transcortical motor aphasia
Wallenberg (lateral medullary) syndrome is the most tested posterior circulation stroke on boards. Remember: ipsilateral = face + Horner + ataxia; contralateral = body pain/temp. Dysphagia is common. It does NOT cause motor weakness (corticospinal tract spared). Nucleus ambiguus involvement → ipsilateral palatal/vocal cord paralysis.
Lacunar Syndromes
Syndrome
Location
Presentation
Pure motor hemiparesis
Posterior limb of internal capsule OR basis pontis
Contralateral face, arm, leg weakness (equal); NO sensory/visual/cortical signs
Pure sensory stroke
VPL nucleus of thalamus
Contralateral numbness/paresthesias face, arm, leg; NO motor deficit
Ataxic hemiparesis
Posterior limb of internal capsule OR pons
Ataxia of the paretic limbs on the same side as the weakness (both contralateral to the lesion), out of proportion to weakness; cerebellar-type ataxia
Dysarthria–clumsy hand
Basis pontis OR anterior limb of internal capsule / genu
Dysarthria + ipsilateral hand clumsiness/weakness; facial weakness common
Mixed sensorimotor
Thalamus extending to posterior limb of internal capsule
Lacunar strokes are small (<1.5 cm), deep infarcts from lipohyalinosis of penetrating arteries. They do NOT cause cortical signs (no aphasia, no neglect, no hemianopia). If cortical signs are present, think embolic or large-artery disease, not lacunar. The most common lacunar syndrome is pure motor hemiparesis. Lacunar infarcts are often NIHSS-low and CT-negative early — MRI DWI is the gold standard.
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