Ischemic strokeMANAGEMENT

NEUROLOGICAL PRESENTATIONS · 12 SECTIONS

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481 items

☷ Legend

01Approach to the Critical Patient/attcp49

Time critical priorities

›Stroke pathway activation

›Last known well time

›Wake up or unwitnessed onset treated as last known well at sleep or baseline time

›Symptom discovery time recorded separately

›Glucose bedside

›Hypoglycemia mimics and immediate correction threshold 3.0 mmol/L

›Persistent neuro deficit after correction treated as possible stroke

›Airway and ventilation

›GCS decline

›Aspiration risk with bulbar dysfunction

›Hemodynamics

›Hypotension evaluation for sepsis hemorrhage dysrhythmia

›Avoid rapid blood pressure drops before imaging unless hypertensive emergency

›Imaging clock

›Noncontrast CT head immediate

›CTA head and neck early for large vessel occlusion screening

›Thrombolysis and thrombectomy eligibility snapshot

›Time windows

›IV thrombolysis window 4.5 hours from last known well

›Endovascular thrombectomy window 6 hours standard

›Endovascular thrombectomy window 6 to 24 hours with favorable imaging selection

›Contraindication sweep

›Active bleeding

›Recent intracranial hemorrhage history

›Recent major surgery or trauma

›Current anticoagulant exposure

›Monitoring and targets

›Oxygenation

›SpO2 target at least 94%

›Routine oxygen avoidance if not hypoxemic

›Temperature

›Fever threshold 38.0 C

›Antipyretic strategy for fever

›Glucose

›Hyperglycemia target 7.8 to 10.0 mmol/L

›Hypoglycemia avoidance

Systems of care

›Transfer and routing decisions

›Large vessel occlusion suspicion

›Direct routing to thrombectomy capable center when feasible

›Do not delay IV thrombolysis for transfer logistics

›Wake up or late window presentation

›Advanced imaging access plan

›Neurology and interventional consultation early

›Time metrics for quality

›Door to CT goal 20 minutes

›Parallel processing for labs registration and IV access

›Door to needle goal 60 minutes

›Consent process minimized to essentials

›Door to groin puncture goal 90 minutes for eligible transfers and arrivals

02History/hx45

Core history elements

›Symptom timeline

›Last known well time

›Witnessed onset

›Wake up symptoms

›Symptom progression pattern

›Sudden maximal deficit suggests vascular

›Stuttering deficits suggests fluctuating perfusion

›Symptom phenotype

›Unilateral weakness

›Aphasia

›Neglect

›Visual field loss

›Gaze deviation

›Ataxia

›Vertigo with brainstem signs

›Bleeding and anticoagulant history

›Antiplatelets

›Warfarin exposure

›DOAC exposure time of last dose

›Heparin exposure

›Comorbid risks

›Atrial fibrillation

›Prior stroke or TIA

›Diabetes

›Hypertension

›Hyperlipidemia

›Smoking and vaping nicotine

›Migraine history

›Seizure history

›Mimic triggers

›Hypoglycemia risk

›Toxic exposure

›Infection symptoms

›Recent head trauma

Pre stroke baseline

›Functional status and disability

›Pre stroke modified Rankin Scale estimate

›Independent baseline supports aggressive reperfusion decisions

›Severe baseline disability influences risk benefit framing

›Usual communication ability

›Usual mobility

›Medication and allergy context

›Antihypertensives

›Diabetes therapies

›Recent thrombolytics exposure within 3 months

›Recent anticoagulant reversal agents

03Physical Exam/exam38

Neurologic exam framework

›NIH Stroke Scale elements

›Level of consciousness

›Gaze

›Visual fields

›Facial palsy

›Motor arm

›Motor leg

›Limb ataxia

›Sensory

›Language

›Dysarthria

›Extinction and inattention

›Posterior circulation screen

›Dysphagia

›Diplopia

›Dysmetria

›Direction changing nystagmus

›Skew deviation

General exam and complications

›Airway and breathing

›Work of breathing

›Aspiration signs

›Cardiovascular

›Rhythm irregularity

›Murmur for endocarditis suspicion

›Signs of heart failure

›Blood pressure and perfusion

›Marked hypertension

›Hypotension

›Bleeding risk clues

›Recent puncture sites

›Ecchymoses

›GI bleeding signs

PITFALLS

›Mimics and confounders

›Postictal Todd paralysis

›Complex migraine

›Functional neurologic disorder

›Sepsis associated encephalopathy

›Intoxication

04Differential Diagnosis/ddx28

Life threatening and time sensitive

›Intracerebral hemorrhage ICD-10 I61

›Sudden headache

›Vomiting

›Decreased level of consciousness

›Subarachnoid hemorrhage ICD-10 I60

›Thunderclap headache

›Meningismus

›Cerebral venous thrombosis ICD-10 I67.6

›Headache with seizure

›Pregnancy or postpartum risk

›Aortic dissection with cerebral ischemia ICD-10 I71.0

›Chest or back pain

›Pulse deficit

›Hypoglycemia ICD-10 E16.2

›Diaphoresis

›Rapid symptom fluctuation with glucose correction

Common stroke mimics

›Seizure with postictal deficit ICD-10 G40

›Witnessed convulsion

›Tongue bite

›Migraine with aura ICD-10 G43

›Spreading positive symptoms

›Prior similar episodes

›Brain tumor ICD-10 C71 or D33

›Subacute progressive deficits

›Demyelinating disease ICD-10 G35

›Prior episodes

›Peripheral vestibular syndrome ICD-10 H81

›Isolated vertigo without focal deficits

05Laboratory Tests/lt32

Immediate point of care

›Bedside glucose

›Treatment threshold 3.0 mmol/L

›IV dextrose strategy per local protocol

›Recheck glucose after treatment

›Hyperglycemia correction threshold 10.0 mmol/L

›Insulin protocol targeting 7.8 to 10.0 mmol/L

›Avoid rapid overcorrection hypoglycemia

Thrombolysis safety labs

›Coagulation profile when indicated

›INR for warfarin exposure

›IV thrombolysis generally avoided if INR above 1.7

›Reversal discussion if hemorrhage not excluded

›aPTT for heparin exposure

›Marked elevation as contraindication for thrombolysis

›Platelet count

›Severe thrombocytopenia as thrombolysis exclusion

›Do not delay thrombolysis for platelets if no reason to suspect abnormality

›Serum creatinine and eGFR

›Contrast planning for CTA and CTP

›Do not delay emergent CTA for mild to moderate renal dysfunction when thrombectomy decision depends on it

Baseline and secondary prevention labs

›CBC

›Baseline hemoglobin for bleeding risk

›Leukocytosis for infection trigger

›Electrolytes

›Sodium abnormalities as mimic contributor

›Potassium for dysrhythmia risk

›Troponin

›Concomitant myocardial ischemia screen

›Neurogenic myocardial injury interpretation caution

›Lipid panel

›LDL target planning

›HbA1c

›Diabetes diagnosis and control baseline

06Diagnostic Tests/dt63

Scoring Systems

›Stroke severity and disability tools

›NIH Stroke Scale

›Baseline value before thrombolysis

›Serial reassessment after reperfusion therapy

›Modified Rankin Scale

›Pre stroke baseline estimate

›Discharge and follow up outcome anchor

›ASPECTS for anterior circulation

›Score 0 to 10

›Lower scores reflect larger early ischemic change

›Large vessel occlusion screening tools

›Prehospital scales

›FAST

›RACE

›LAMS

›Performance limitations

›False negatives in distal occlusions

›False positives in mimics

MRI

›MRI brain with DWI and FLAIR

›Wake up stroke selection

›DWI positive with FLAIR negative mismatch supports recent onset

›Thrombolysis consideration in selected patients when CT based selection not sufficient

›Posterior circulation ischemia

›Higher sensitivity than noncontrast CT for early brainstem infarct

›Contraindications

›Non MRI compatible implants

›Unstable patient requiring continuous interventions

›Noncontrast CT head

›Hemorrhage exclusion

›Immediate triage for thrombolysis pathway

›Hyperdense artery sign as large vessel occlusion clue

›Early ischemic changes

›Loss of gray white differentiation

›Sulcal effacement

›ASPECTS estimation support

›CT angiography head and neck

›Large vessel occlusion identification

›ICA terminus

›M1 MCA

›Basilar artery

›Tandem lesion detection

›Cervical ICA stenosis or occlusion

›Collateral assessment

›Poor collaterals predict larger core growth

›CT perfusion

›Late window thrombectomy selection

›Core infarct estimate

›Penumbra mismatch estimate

›Limitations

›Motion artifact

›Variability across software and thresholds

Ultrasound

›Point of care ultrasound use cases

›Cardiac ultrasound

›Gross LV function

›Pericardial effusion if hypotension

›Carotid duplex

›Non emergent inpatient evaluation for carotid stenosis

›Not a substitute for emergent CTA when thrombectomy decision required

›Lower limb venous ultrasound

›DVT evaluation in immobilized patients

›Transcranial Doppler

›Microemboli detection in specialized centers

›Recanalization monitoring where available

07Disposition/dispo18

Level of care decisions

›ICU level indications

›Post IV thrombolysis monitoring for 24 hours

›Post mechanical thrombectomy monitoring

›Large infarct risk for edema

›Need for continuous antihypertensive infusion

›Airway risk

›Stroke unit admission indications

›Most ischemic strokes without ICU triggers

›Early rehab initiation planning

›Transfer criteria

›Suspected large vessel occlusion with thrombectomy eligibility

›Posterior circulation stroke with basilar occlusion concern

›Need for neurosurgical decompression capability

Discharge and rapid outpatient pathways

›TIA or minor stroke discharge only in selected low risk contexts

›Rapid access stroke clinic within 24 to 72 hours

›Antiplatelet and statin initiation plan

›Clear return precautions

›Ability to obtain urgent vascular imaging and cardiac monitoring

08Treatment/t100

Reperfusion therapy

›IV thrombolysis eligibility and selection

›Time criteria

›Last known well within 4.5 hours

›Unknown onset with advanced imaging selection in specialized pathways

›Imaging criteria

›No intracranial hemorrhage on noncontrast CT

›No large established infarct pattern suggesting high hemorrhage risk

›Blood pressure criteria

›Before thrombolysis below 185 over 110 mmHg

›After thrombolysis below 180 over 105 mmHg for 24 hours

›Alteplase dosing

›0.9 mg per kg IV

›Maximum 90 mg

›10 percent as IV bolus over 1 minute

›Remaining 90 percent infused over 60 minutes

›Tenecteplase dosing in eligible pathways

›0.25 mg per kg IV bolus

›Maximum 25 mg

›Avoid 0.40 mg per kg dosing

›Antithrombotics after thrombolysis

›No antiplatelet or anticoagulant for 24 hours

›Repeat brain imaging at 24 hours before starting antithrombotics

›Endovascular mechanical thrombectomy

›Occlusion targets

›Anterior circulation ICA or proximal MCA occlusion

›Basilar artery occlusion in selected cases

›Time and imaging selection

›Within 6 hours with appropriate clinical imaging match

›6 to 24 hours with perfusion or collateral based selection

›Bridging thrombolysis

›IV thrombolysis given when eligible even if thrombectomy 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 first 24 hours when treatment required

›Pre thrombolysis blood pressure lowering

›Labetalol IV bolus options

›10 to 20 mg IV over 1 to 2 minutes

›Repeat once if needed

›Nicardipine infusion

›Initiate 5 mg per hour

›Titrate 2.5 mg per hour every 5 to 15 minutes

›Maximum 15 mg per hour

›Clevidipine infusion

›Initiate 1 to 2 mg per hour

›Double dose every 2 to 5 minutes until near goal

›Usual maximum 21 mg per hour

›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

Antithrombotic therapy

›Aspirin for non thrombolysed ischemic stroke

›160 to 325 mg daily within 24 to 48 hours

›Swallow safety prerequisite or rectal route

›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

›High risk TIA in specialist pathway

›Regimen duration

›21 days typical

›Transition to single antiplatelet thereafter

›Anticoagulation for cardioembolic stroke

›Atrial fibrillation confirmed or strongly suspected

›Timing individualized to infarct size and hemorrhage risk

›Small infarct earlier start

›Large infarct delayed start

Supportive care and complication prevention

›Swallow and aspiration prevention

›NPO until swallow screen passed

›Speech language pathology referral

›DVT prevention

›Intermittent pneumatic compression

›Pharmacologic prophylaxis timing

›After 24 hour imaging post thrombolysis

›Earlier in non thrombolysed patients if no hemorrhage

›Cerebral edema and herniation risk management

›Large hemispheric infarct monitoring

›Declining level of consciousness trigger

›Repeat imaging trigger

›Osmotherapy and neurosurgery consultation triggers

›Mannitol or hypertonic saline per ICU protocol

›Decompressive hemicraniectomy window discussion in malignant MCA

›Seizure management

›Treat clinical seizures

›No routine prophylactic antiseizure medication

›Temperature and glucose control

›Fever treatment

›Glucose target 7.8 to 10.0 mmol/L

Secondary prevention initiated inpatient

›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

›Echocardiography selection

›Vascular imaging review

09Special Populations/sp37

Pregnancy

›Pregnancy specific considerations

›Maternal benefit priority in disabling stroke

›IV thrombolysis considered when benefits outweigh risks

›Mechanical thrombectomy preferred for large vessel occlusion when feasible

›Imaging considerations

›Noncontrast CT head acceptable with fetal shielding

›CTA and CTP risk benefit discussion with emergent decision making

›Antithrombotic choices

›Avoid warfarin in pregnancy

›LMWH preferred when anticoagulation indicated

›Obstetric coordination

›Maternal fetal medicine consultation

›Delivery planning if severe stroke complications

Geriatric

›Older adult considerations

›Pre stroke disability and goals of care

›Modified Rankin baseline integration into thrombectomy decisions

›Frailty and delirium risk

›Medication sensitivity

›Lower tolerance of hypotension

›Higher bleeding risk with antithrombotics

›Atypical presentations

›Delirium dominant presentation

›Falls as presenting complaint

Pediatrics

›Pediatric stroke pathway

›Stroke mimic prevalence higher than adults

›Migraine

›Seizure

›Bell palsy

›Etiologies

›Congenital heart disease

›Sickle cell disease

›Arteriopathy and dissection

›Imaging and consultation

›Pediatric neurology urgent involvement

›MRI often preferred when stable and available

›Reperfusion therapies

›Thrombolysis and thrombectomy only in specialized pediatric capable centers with individualized selection

10Background/b31

Epidemiology

›Stroke burden

›Ischemic strokes comprise about 85 percent of all strokes

›Hemorrhagic strokes comprise about 15 percent of all strokes

›Large vessel occlusion proportion around one quarter to one third of ischemic strokes

›Outcome impact of time

›Neuronal loss rate about 1.9 million neurons per minute in untreated large vessel occlusion

›Earlier reperfusion associated with better functional outcomes

Pathophysiology

›Ischemic cascade

›Arterial occlusion causes core infarct and penumbra

›Core irreversible injury without timely reperfusion

›Penumbra salvageable with reperfusion

›Excitotoxicity and ion pump failure

›Cytotoxic edema followed by vasogenic edema

›Mechanisms and subtypes

›Large artery atherosclerosis

›Cardioembolism

›Small vessel occlusion

›Other determined etiology

›Cryptogenic stroke and ESUS concept

Therapeutic Considerations

›Thrombolysis rationale

›Fibrinolysis improves odds of functional independence when given early

›Symptomatic intracranial hemorrhage risk balanced against disability from untreated stroke

›Thrombectomy rationale

›Mechanical clot retrieval improves outcomes in large vessel occlusion

›Imaging selection extends benefit to 24 hours in selected patients

›Blood pressure strategy rationale

›Permissive hypertension supports collateral perfusion

›Excessive hypertension increases hemorrhagic transformation risk after reperfusion therapies

›Antiplatelet and anticoagulant rationale

›Antiplatelets reduce early recurrence in non cardioembolic stroke

›Anticoagulation reduces recurrence in atrial fibrillation related stroke

11Patient Discharge Instructions/pdi25

copy discharge instructions

›Stroke and TIA discharge packet

›Diagnosis summary

›Ischemic stroke or transient ischemic attack explanation in plain language

›Major risk factors identified

›Medications

›Antiplatelet schedule and duration

›Statin schedule

›Anticoagulant schedule if prescribed

›Blood pressure and diabetes medication plan

›Activity and safety

›No driving until cleared by clinician per local rules

›Swallow safety and diet recommendations if applicable

›Fall prevention strategies

›Follow up

›Stroke clinic appointment date and contact

›Family doctor follow up within 1 week

›Cardiac monitoring plan if arranged

›Return to ED immediately for red flags

›New or worsening weakness numbness or speech difficulty

›New facial droop

›New severe headache

›New confusion or fainting

›New vision loss or double vision

›Chest pain or shortness of breath

›Any major bleeding on antithrombotics

12References/r15

Clinical guidelines and landmark evidence

›Source set used for this checklist

›AHA ASA guideline for early management of acute ischemic stroke 2019 update

›Canadian Stroke Best Practices acute ischemic stroke treatment recommendations

›Tenecteplase evidence summaries

›European Stroke Organisation expedited recommendation on tenecteplase 0.25 mg per kg for eligible acute ischemic stroke

›Randomized trials comparing tenecteplase and alteplase in bridging thrombectomy pathways

›Thrombectomy late window trials

›DAWN trial imaging selected thrombectomy up to 24 hours

›DEFUSE 3 trial imaging selected thrombectomy up to 16 hours

›Dual antiplatelet trials in minor stroke and TIA

›CHANCE trial

›POINT trial

›Stroke unit and supportive care evidence

›Stroke unit care improves mortality and functional outcomes compared with general ward care

›Intermittent pneumatic compression reduces DVT in immobile stroke patients

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.