›Within 6 hours with appropriate clinical imaging match
›6 to 24 hours with perfusion, collateral, or posterior circulation imaging-based selection in randomized-trial-supported protocols
›Bridging thrombolysis
›IV thrombolysis given when eligible even if thrombectomy is planned
›Door in door out efficiency for transfer patients
Blood pressure management
›No thrombolysis or thrombectomy planned
›Permissive hypertension
›Treat only if above 220 over 120 mmHg
›Gradual reduction around 15 percent in the first 24 hours when treatment is required
›Chronic hypertension, dialysis, and pregnancy exceptions
›Chronic hypertensive patients may have shifted cerebral autoregulation and tolerate the same numeric threshold poorly if lowered abruptly
›Dialysis patients require individualized targets coordinated with nephrology
›Pregnancy-associated hypertension uses a lower treatment threshold consistent with obstetric hypertensive emergency criteria
›Pre thrombolysis blood pressure lowering
›Labetalol IV bolus options
›10 to 20 mg IV over 1 to 2 minutes
›Repeat once if needed
›If bradycardia or hypotension risk, omit the bolus and proceed directly to an infusion-based agent
›Nicardipine infusion
›Initiate 5 mg per hour
›Titrate 2.5 mg per hour every 5 to 15 minutes
›Maximum 15 mg per hour
›Deceleration step, once within 10 percent of target slow titration increments to the smallest available step
›Clevidipine infusion
›Initiate 1 to 2 mg per hour
›Double the dose every 2 to 5 minutes until near goal
›Usual maximum 21 mg per hour
›Deceleration step, once within 10 percent of target switch to fixed small increments rather than doubling
›Post reperfusion therapy blood pressure
›Target below 180 over 105 mmHg for 24 hours after thrombolysis
›Post thrombectomy targets per reperfusion status
›Avoid hypotension
›Tighter targets in successful reperfusion considered in specialist protocols
›Herniation caution
›In a patient with suspected rising intracranial pressure and Cushing-pattern hypertension, aggressive blood pressure lowering can precipitate herniation by collapsing cerebral perfusion pressure
›Coordinate blood pressure targets with neurosurgery when fourth ventricle compression or hydrocephalus is present
›Do not treat Cushing-pattern hypertension as a routine hypertensive emergency
Cerebellar edema and hydrocephalus management
›Hyperosmolar therapy as a bridge to surgery
›Mannitol
›0.25 to 1 g per kg IV bolus over 20 to 30 minutes
›May repeat every 6 hours
›Hold further dosing if serum osmolality exceeds 320 mOsm/kg
›Foley catheter for diuresis monitoring
›Assess volume status before dosing, since the osmotic diuresis can worsen hypotension in a volume-depleted patient
›Hypertonic saline 3 percent
›Bolus 150 to 250 mL IV over 15 to 20 minutes
›May repeat as needed
›Central venous access preferred for continuous infusion
›Continuous infusion 25 to 50 mL per hour titrated to serum sodium
›Target serum sodium 145 to 155 mmol/L
›Monitor serum sodium every 4 to 6 hours during infusion
›Do not exceed a correction rate that raises sodium more than 8 to 10 mmol/L in 24 hours if baseline sodium is not already elevated
›Hypertonic saline 23.4 percent for impending herniation
›30 mL IV over 10 to 20 minutes via central line only
›Reserved for acute deterioration, not routine escalation
›Pediatric dosing
›Hypertonic saline 3 percent 2 to 5 mL per kg IV over 10 to 20 minutes for acute herniation signs
›Verify against current pediatric guideline before use
›Mannitol 0.25 to 1 g per kg IV, the same weight-based range as adult dosing
›Verify against current pediatric guideline before use
›Osmotherapy is not working
›Continued decline in level of consciousness or brainstem signs despite maximal medical therapy
›Escalate immediately to surgical decompression rather than repeating or increasing osmotherapy
›Mass effect at the fourth ventricle and foramina is a mechanical obstruction that medical therapy alone does not relieve
›External ventricular drain
›Indicated for obstructive hydrocephalus from fourth ventricle compression
›Placement without addressing posterior fossa mass effect risks upward transtentorial cerebellar herniation
›Discuss combined or staged decompressive surgery with neurosurgery rather than EVD alone in a mass lesion
›Suboccipital decompressive craniectomy
›AHA/ASA guideline supports decompressive suboccipital craniectomy with duraplasty as a Class I recommendation for cerebellar infarction causing neurological deterioration from brainstem compression
›Timing
›Performed emergently on clinical deterioration, not deferred until after a trial of medical therapy has failed over hours
›Coordinate with neurosurgery on candidacy even in a patient who initially appears stable, given the delayed swelling window
›Aspirin for non-thrombolysed ischemic stroke
›160 to 325 mg daily within 24 to 48 hours
›Swallow safety prerequisite or rectal route if dysphagia present
›Aspirin after thrombolysis
›Start after 24 hour imaging excludes hemorrhage
›Dual antiplatelet therapy for minor stroke and high risk TIA
›Candidate profile
›NIHSS 3 or less minor ischemic stroke, recognizing that a low NIHSS in a posterior circulation stroke can still represent a disabling deficit
›High risk TIA in a specialist pathway
›Regimen
›Aspirin 81 mg daily plus clopidogrel 75 mg daily for 21 days
›Transition to a single antiplatelet agent thereafter
›Anticoagulation for cardioembolic or dissection-related stroke
›Atrial fibrillation confirmed or strongly suspected, timing individualized to infarct size and hemorrhage risk
›Vertebral artery dissection, antiplatelet or anticoagulant choice individualized with neurology, with either considered reasonable in most cases
Supportive care and iatrogenic harms
›Airway management
›Intubation
›Indicated for airway compromise, declining consciousness, or planned decompressive surgery
›Avoid extremes of PaCO2 during and after intubation, since hypercapnia raises intracranial pressure and hypocapnia can worsen cerebral perfusion
›Minimize hemodynamic swings during laryngoscopy in a patient with borderline cerebral perfusion pressure
›Sedation
›Use the lowest effective dose and shortest-acting agents to preserve the ability to perform neuro checks
›Scheduled sedation interruption for examination where hemodynamically tolerated
›Oversedation masking a new brainstem sign is a preventable cause of delayed neurosurgical recognition
›Fluid loading
›Isotonic fluids only, avoid hypotonic fluids which can worsen cerebral edema
›Avoid unnecessary volume loading once euvolemic, since it does not improve reperfusion and can complicate concurrent hyperosmolar therapy
›Oxygen
›Supplemental oxygen only if hypoxemic
›Routine high-flow oxygen in a normoxic patient has not shown benefit and is not indicated
›Vasopressors
›Not routinely needed given the permissive hypertension strategy
›If hypotension follows sedation, intubation, or post-decompression physiology, support blood pressure rather than allowing hypotension in a patient with impaired cerebral perfusion reserve
›Mechanical circulatory support including intra-aortic balloon pump
›Not indicated for isolated posterior circulation stroke
›If comorbid cardiogenic shock requires consideration, the systemic anticoagulation required for mechanical circulatory support conflicts directly with the bleeding risk of recent thrombolysis or a large infarct, and requires joint cardiology and neurology decision-making
›Anticoagulation timing
›Hold for 24 hours after thrombolysis and until repeat imaging excludes hemorrhagic transformation
›In dissection or cardioembolic stroke, resist early initiation in a large infarct given hemorrhagic transformation risk
›Fibrinolysis for a concurrent condition
›Systemic fibrinolysis for a concurrent diagnosis such as pulmonary embolism is essentially contraindicated within the acute post-stroke window given intracranial hemorrhage risk
›Discuss alternatives such as catheter-directed therapy or mechanical intervention with the relevant specialty
›Analgesia
›Treat significant pain, since uncontrolled pain raises blood pressure and intracranial pressure
›Use judiciously to avoid respiratory depression and hypercapnia
›Acetaminophen 650 to 1000 mg PO or IV every 6 hours, maximum 4000 mg per day, as a first-line non-sedating option
›Opioids in the smallest effective dose if needed, with attention to sedation masking the neuro exam
›Nausea and vomiting
›Ondansetron 4 to 8 mg IV or PO every 4 to 8 hours, maximum 32 mg per day
›QTc monitoring with repeated dosing
›Vestibular-suppressant options limited to the acute phase only
›Meclizine 25 mg PO every 6 to 8 hours if used
›Diazepam 2 to 5 mg PO or IV for severe symptoms if used, respiratory depression risk at higher doses
›Beyond several days these agents inhibit central vestibular compensation and add sedation that masks neurologic decline
›Seizure management
›Treat clinical seizures
›No routine prophylactic antiseizure medication
›DVT prevention
›Intermittent pneumatic compression
›Pharmacologic prophylaxis timing after 24 hour imaging post-thrombolysis, or earlier in non-thrombolysed patients without hemorrhage
›Temperature control
›Acetaminophen 650 to 1000 mg PO or IV every 6 hours, maximum 4000 mg per day, for fever above 38.0 C
›High intensity statin
›Atorvastatin 40 to 80 mg daily in atherosclerotic stroke unless contraindicated
›Blood pressure long term plan
›Start or resume antihypertensives after neurologic stability
›Smoking cessation support
›Etiology workup plan
›Telemetry and rhythm monitoring for atrial fibrillation
›Echocardiography selection
›Vascular imaging review for dissection or atherosclerotic disease