Approach to the Critical Patient

Immediate stabilization

Time-critical actions (first 10 minutes)

Hemodynamic and monitoring targets

Blood pressure management

Monitoring bundle

Team activation and escalation triggers

Neurointerventional team activation

Neurosurgical consultation triggers

Transfer triggers (non-thrombectomy-capable centers)

Key decision points

LVO screening prehospital and at triage

Malignant MCA syndrome recognition

History

Symptom onset and timeline

Time last known well

Acute focal neurologic deficits

Cardioembolic clues

Palpitations or known atrial fibrillation

Recent cardiac procedures or interventions

Known structural heart disease

Patent foramen ovale with atrial septal aneurysm

Vascular risk history

Prior stroke or TIA

Carotid or intracranial atherosclerosis

Hypertension, diabetes mellitus, hyperlipidemia, smoking

Obesity and obstructive sleep apnea

Thrombolysis risk screening

Recent surgery or trauma

Anticoagulant use

History of intracranial hemorrhage, aneurysm, or AVM

Active internal bleeding or known bleeding diathesis

Infective endocarditis or aortic arch dissection (absolute contraindications)

Severe head trauma within 3 months

Functional and collateral history

Pre-stroke functional status (modified Rankin Scale 0–1 is standard thrombectomy criterion)

Baseline cognitive status and independence in ADLs

Advance directives and goals of care

Living situation and available support system

Collateral from bystanders or family regarding exact onset

Physical Exam

Vital signs

Blood pressure (both arms if dissection suspected)

Heart rate and rhythm

Temperature

Oxygen saturation and respiratory rate

Point-of-care glucose

NIHSS assessment (National Institutes of Health Stroke Scale)

Level of consciousness

Gaze

Visual fields

Facial palsy

Motor limb function

Limb ataxia

Sensory

Language (aphasia)

Dysarthria

Extinction and neglect

Cardiovascular and vascular exam

Cardiac auscultation

Carotid auscultation

Peripheral vascular examination

Signs suggesting specific syndromes

Anterior circulation (ICA or MCA) LVO pattern

Posterior circulation (basilar artery) pattern

Malignant edema signs

Differential Diagnosis

Cannot-miss diagnoses

Intracerebral hemorrhage (ICH)

Basilar artery occlusion

Subarachnoid hemorrhage (SAH)

Cervical artery dissection

Aortic arch dissection with cerebrovascular involvement

Stroke mimics (important)

Hypoglycemia

Seizure with Todd's paralysis

Complex migraine with aura

Hypertensive encephalopathy / PRES

Intracranial mass lesion or abscess

Functional neurological disorder

Wernicke encephalopathy

Laboratory Tests

Mandatory stat labs

Point-of-care glucose

Complete blood count

Coagulation panel

Basic metabolic panel

Cardiac troponin

Secondary workup labs

Lipid panel

HbA1c

Thyroid function tests

Urine toxicology

Blood cultures

Hypercoagulability panel (selected patients)

Type and screen

Biomarker considerations

GFAP (glial fibrillary acidic protein) — emerging prehospital LVO screening biomarker

Lactate

Arterial blood gas

Diagnostic Tests

Scoring Systems

NIHSS (National Institutes of Health Stroke Scale)

ASPECTS (Alberta Stroke Program Early CT Score)

Modified Rankin Scale (mRS)

RACE Scale (Rapid Arterial oCclusion Evaluation) — prehospital LVO detection

DAWN Trial criteria (6–24 hour window)

DEFUSE-3 criteria (6–16 hour window)

MRI

MRI indications in acute LVO

DWI (diffusion-weighted imaging)

PWI (perfusion-weighted imaging)

MRA (MR angiography)

FLAIR (fluid-attenuated inversion recovery)

MRI contraindications and limitations

CT

Non-contrast CT (NCCT) head — first-line imaging

CT Angiography (CTA) head and neck

CT Perfusion (CTP)

CT angiography neck

Ultrasound

Carotid duplex ultrasound

Transcranial Doppler (TCD)

Echocardiography

Point-of-care cardiac ultrasound (ED POCUS)

Disposition

Acute admission criteria

All LVO patients require inpatient admission

Transfer indications (non-thrombectomy-capable center)

Level of care decisions

ICU admission

Stroke unit (step-down)

Inpatient general neurology/medicine

Specialist consultations

Required consultations

Discharge and follow-up planning

Discharge criteria

Outpatient follow-up

Treatment

IV thrombolysis

Alteplase 0.9 mg/kg IV (maximum 90 mg)

Tenecteplase 0.25 mg/kg IV (maximum 25 mg) — single bolus

Absolute contraindications to IV thrombolysis

Post-thrombolysis monitoring

Mechanical thrombectomy (EVT)

Standard window (0–6 hours) — Class IA recommendation

Extended window (6–24 hours) — Class IA recommendation (DAWN/DEFUSE-3 criteria)

Large core infarction (ASPECTS 3–5) — emerging indication

Basilar artery occlusion thrombectomy

Thrombectomy technique options

Blood pressure management (detailed)

Pre-thrombolysis BP lowering agents

Post-reperfusion BP targets

Antithrombotic therapy (post-acute)

Aspirin 325 mg orally

High-intensity statin therapy

Anticoagulation for cardioembolic etiology (AF)

Dual antiplatelet therapy (DAPT) for non-cardioembolic stroke

Neuroprotective and supportive care

Glycemic control

Temperature management

DVT prophylaxis

Dysphagia management

Osmotherapy for malignant cerebral edema

Seizure management

Special Populations

Pregnancy

Epidemiology and risk in pregnancy

IV thrombolysis in pregnancy

Mechanical thrombectomy in pregnancy

BP management in pregnancy

Anticoagulation considerations

Delivery planning

Geriatric

LVO prevalence in geriatric patients

Thrombolysis in elderly patients

Thrombectomy in elderly patients

BP considerations in elderly

Medication considerations

Goals of care in severe stroke

Pediatrics

Pediatric ischemic stroke overview

Etiology differences from adults

Thrombolysis in children

Thrombectomy in children

Sickle cell specific management

Recognition challenges in children

Background

Epidemiology

Incidence and prevalence

Mortality and morbidity

Risk factor prevalence

Vessel distribution of LVO

Pathophysiology

Ischemic cascade

Etiology classification (TOAST criteria)

Collateral circulation

Hemorrhagic transformation

Therapeutic Considerations

Reperfusion therapy evidence base

Secondary prevention evidence

Cryptogenic stroke and PFO

Neuroprotection limitations

Patient Discharge Instructions

copy discharge instructions

What happened to you

Your medications

Activity and diet

Follow-up appointments

Return to the emergency department immediately if you develop

Risk factor control

Warning about stroke signs (FAST)

References

Guidelines and key sources

AHA/ASA 2026 Guideline for Early Management of Patients with Acute Ischemic Stroke

AHA/ASA 2018 Guideline for Early Management of Patients with Acute Ischemic Stroke

ACR Appropriateness Criteria — Cerebrovascular Diseases

Landmark trials

DAWN trial — thrombectomy 6–24 hours (clinical-core mismatch)

DEFUSE-3 trial — thrombectomy 6–16 hours (perfusion mismatch)

AURORA meta-analysis (Lancet 2022)

ANGEL-ASPECT trial — EVT for large core (ASPECTS 3–5)

AcT trial — tenecteplase vs alteplase

Systematic reviews and consensus documents

Endovascular Management of Acute Stroke (Lancet 2024)

Antithrombotic Therapy for Prevention of Ischemic Stroke (JACC 2023)

PRESTO study — prehospital LVO detection scales (Lancet Neurology 2021)

DETECT LVO trial — GFAP plus clinical scoring for prehospital LVO detection (Stroke 2026)

ACC Expert Consensus — Arrhythmia Monitoring After Stroke (JACC 2025)