›Two IV lines if candidate for thrombolysis or thrombectomy
›Noncontrast CT head target within 20 minutes local protocol dependent
Acute stroke pathway
›Reperfusion decision workflow
›Noncontrast CT head for hemorrhage exclusion
›CTA head and neck for large vessel occlusion when eligible local protocol dependent
›Thrombolysis eligibility screen local protocol dependent
›Thrombectomy eligibility screen local protocol dependent
Blood pressure targets
›Blood pressure management local protocol dependent
›If thrombolysis planned maintain BP below 185 over 110 mmHg
›After thrombolysis maintain BP below 180 over 105 mmHg
›If no thrombolysis and BP greater than 220 over 120 mmHg consider cautious reduction
Glucose and temperature
›Physiologic targets
›Glucose target 7 to 10 mmol/L local protocol dependent
›Treat hypoglycemia immediately
›Treat fever and search source
Antithrombotic therapy
›Antiplatelet and anticoagulation local protocol dependent
›Aspirin after hemorrhage excluded
›Dual antiplatelet for high risk TIA or minor stroke when appropriate local protocol dependent
›Anticoagulation timing for atrial fibrillation stroke depends on infarct size local protocol dependent
Seizure management
›Seizure treatment if present
›Lorazepam IV 2 mg
›Repeat 2 mg every 2 minutes up to 8 mg total local protocol dependent
›Airway risk monitoring
›Levetiracetam IV 60 mg per kg
›Maximum 4500 mg
›Renal adjustment local protocol dependent
Reassessment loop
›Reassessment loop
›Neuro checks frequency local protocol dependent
›Repeat glucose after correction
›Repeat vitals after BP interventions
›Escalate for worsening NIHSS or declining consciousness
17Disposition/dispo23
Level of care criteria
›ICU or higher acuity criteria
›Intracranial hemorrhage
›Large vessel occlusion awaiting intervention
›Airway compromise
›Refractory seizure
›Severe BP instability
Admission and observation
›Admission criteria
›Persistent neurologic deficit
›TIA with high short term stroke risk features
›Need for urgent carotid or cardioembolic workup
›Anticoagulation management complexity
›Observation pathway criteria local protocol dependent
›Resolved deficit with rapid access imaging and neurology follow up
›Stable vitals and reliable supervision
Transfer criteria
›Transfer to thrombectomy capable center local protocol dependent
›Suspected large vessel occlusion
›Within endovascular time window per protocol
›No prohibitive comorbidity or goals of care limitations
Discharge criteria
›Discharge criteria
›Stroke and hemorrhage excluded with appropriate imaging
›Mimic identified and treated
›Normal neurologic exam at baseline
›Reliable follow up within 24 to 72 hours for TIA pathway local protocol dependent
18Discharge Instructions/di20
Copy discharge instructions
›Summary
›You were seen for a sudden change in speech or language
›Your tests today did not show bleeding in the brain
›A stroke can still happen even if symptoms improve
›Medications
›Take medications exactly as prescribed
›Do not stop blood thinners without medical advice
›Activity
›Do not drive until cleared if you had a seizure or stroke concern
›Avoid alcohol and sedating substances until symptoms fully resolved
›Follow up
›Return for urgent follow up within 24 to 72 hours if advised
›Neurology or stroke clinic follow up timing as arranged
›Return to ED now for
›Any new or worsening weakness
›Any new or worsening speech or understanding problems
›Severe sudden headache
›Seizure
›Confusion or fainting
›Chest pain or trouble breathing
19References/r6
Guidelines and key sources
›Evidence based references
›American Heart Association American Stroke Association guidelines for early management of acute ischemic stroke 2019 update
›American Heart Association American Stroke Association guideline for the prevention of stroke in patients with stroke and TIA 2021
›European Stroke Organisation guidelines for management of acute ischemic stroke and TIA 2021 to 2023 local protocol dependent
›Society of NeuroInterventional Surgery recommendations for endovascular thrombectomy systems of care 2021 local protocol dependent
›NIH Stroke Scale training and certification materials current version local protocol dependent
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.