Acute Stroke

• Activate the stroke team / telestroke; establish IV access and monitoring.
• ABCs + Glucose: Support airway / ventilation; correct hypoglycemia, hypoxemia, and hypotension.
• Establish last known well, symptom discovery, baseline function, and anticoagulant / last dose. See Initial Evaluation.

• Define the deficit: language, vision, gaze, face, strength, sensation, coordination, and neglect.
• NIHSS + What Can The Patient No Longer Do? Low NIHSS does not mean nondisabling. Correct plausible reversible causes without exhaustive mimic testing.
• Resolved symptoms still require ischemia assessment; a negative MRI does not independently settle TIA versus stroke. See Clinical Assessment.

• Noncontrast CT → Hemorrhage? If present, follow the Intracranial Hemorrhage pathway.
• CTA Head / Neck → Occlusion Or Dissection? Obtain promptly when indicated.
• Normal CT does not exclude ischemic stroke. Use MRI / perfusion for selected diagnostic or extended-window questions without delaying indicated early IVT. See Imaging.

• Assess IV Thrombolysis (IVT) And Endovascular Thrombectomy (EVT) Together—Not One After The Other.
• Disabling Ischemic Deficit: Standard IVT window ≤4.5 hours; complete the safety / BP assessment.
• Occlusion Suitable For Thrombectomy: Immediate specialist assessment / transfer; selected patients qualify through 24 hours. Do not wait for IVT response.
• Wake-Up / Late Presentation: Imaging-based selection may permit treatment. Truly nondisabling deficits require continued evaluation and an appropriate antiplatelet pathway. See Reperfusion.

• BP: Use the target for IVT / thrombectomy / neither; correct hypotension.
• Antiplatelets: After hemorrhage exclusion and the reperfusion decision; selected minor noncardioembolic stroke / high-risk TIA → short-course dual antiplatelet therapy (DAPT).
• After IVT: Generally withhold antithrombotics for 24 hours and obtain follow-up imaging before starting.
• Swallowing: Nothing by mouth until swallowing safety is assessed; treat significant glucose abnormalities and fever. See Immediate Care.

• Repeat the deficit, consciousness, BP, glucose, and breathing. Deterioration → immediate reassessment / imaging.
• Discharge: Selected TIA after appropriate initial assessment, prevention, and a secured rapid follow-up pathway.
• Monitored Admission: Stroke, high-risk TIA, or required post-reperfusion monitoring.
• ICU Admission: Airway / hemodynamic support, major treatment complications, or neurologic deterioration. See Disposition.

• Stroke Activation: Involve the stroke team / telestroke service; obtain IV access, cardiac monitoring, bedside glucose, and rapid imaging.
• Airway: Assess consciousness, bulbar function, ventilation, and airway protection. Intubate when these fail; GCS alone is not the decision.
• Oxygenation: Treat hypoxemia to maintain SpO₂ >94%. Routine oxygen for every normoxic patient is unnecessary; selected thrombectomy protocols are separate. AHA/ASA 2026 — Airway / Oxygenation.
• Glucose / Perfusion: Correct hypoglycemia, hypotension, and clinically important volume depletion; repeat the examination after correction. AHA/ASA 2026 — Supportive Care.

• Record last known well, symptom discovery, and witnessed onset separately. Obtain the witness's account and contact information.
• Wake-up symptoms: Awakening is not last known well. Document fluctuations and any convincing interval of complete recovery; partial improvement does not reset the clock.
• Review baseline independence, mobility, cognition, communication, and existing deficits.
• Review anticoagulants / last doses, antiplatelets, recent bleeding, surgery, trauma, and intracranial disease. Baseline disability requires individualized assessment rather than automatic exclusion. AHA/ASA 2026 — Eligibility.

• Hemispheric: Unilateral weakness / numbness, aphasia, neglect, gaze preference, or visual-field loss.
• Deep / Lacunar: Pure motor, pure sensory, or sensorimotor deficits may arise from subcortical injury. Combined motor and sensory loss does not establish a cortical lesion.
• Posterior Circulation: Diplopia, dysarthria, dysphagia, abnormal eye movements, crossed findings, severe gait / truncal ataxia, or reduced consciousness. Vertigo may dominate.
• Dissection: New headache / neck pain, painful Horner syndrome, or relevant trauma. Chest / back pain with pulse or perfusion abnormalities raises concern for aortic disease.
• Endocarditis: Fever, bacteremia risk, embolic findings, or a concerning murmur. This changes reperfusion safety as well as the differential. AHA/ASA 2026 — Special Circumstances.
• Examine language, gaze, visual fields, face, limb strength / sensation, coordination, and neglect; assess gait when safe. Clinical localization directs imaging but does not replace it. AHA 2023 — Clinical Assessment.

• Document NIHSS at baseline and after treatment or clinical change.
• Low NIHSS can still be disabling: Aphasia, visual loss, or inability to walk may prevent usual activities despite a low total score.
• Assess communication, ambulation, self-care, and usual work. Improvement that leaves a disabling deficit is not complete recovery. AHA/ASA 2026 — Disability.

• TIA: Transient focal ischemic dysfunction with complete recovery and no demonstrated acute infarction.
• Ischemic Stroke: Neurologic dysfunction caused by focal infarction; symptoms may persist or resolve. A relevant acute infarct establishes stroke even after full recovery. AHA/ASA — Definitions.
• Apply the following distinctions when the clinical event is most consistent with ischemia—not solely because focal symptoms occurred.

• Bedside Example: Three hours of hemiparesis, full recovery, and negative DWI generally fits TIA when the history supports ischemia. The same episode with a corresponding acute infarct is stroke. AHA 2023 — TIA Definition.
• Negative MRI is not proof that no infarction occurred. Small, early, and posterior-circulation infarcts may be missed; symptoms and trajectory still matter. See MRI Limitations. Edlow 2017.
• Persistent focal ischemic deficits ≥24 hours, with other causes excluded, can establish clinical evidence of infarction despite negative imaging. Do not wait 24 hours to diagnose suspected stroke or assess reperfusion; this is a classification criterion, not a treatment delay. AHA/ASA — Clinical Definition.

• Hypoglycemia: Correct and reassess; persistent focal deficits still require stroke evaluation.
• Seizure / Postictal Weakness: Assess the witnessed sequence and recovery. Seizure at onset does not prove that the remaining deficit is postictal.
• Migraine Aura: Prior identical episodes and spreading symptoms support the diagnosis; a first or atypical event requires further assessment.
• Other Causes: Toxic / metabolic disturbance, hypertensive encephalopathy, infection, or mass lesion when supported by the presentation.
• Functional Symptoms: Require positive clinical findings—not a psychiatric history or normal CT alone.
• Do not delay eligible treatment for exhaustive mimic testing; resolve material uncertainty with the stroke team. AHA/ASA 2026 — Diagnostic Uncertainty.

• Exclude hemorrhage, assess established ischemic injury, and identify major alternatives.
• Early ischemic findings include loss of gray–white differentiation, sulcal effacement, or a hyperdense artery. A normal CT does not exclude acute ischemic stroke.
• ASPECTS describes early anterior-circulation injury; interpret it within the reperfusion pathway rather than as a universal exclusion. AHA/ASA 2026 — Imaging.

• Identify large-vessel occlusion, relevant stenosis, or dissection. Contact the thrombectomy team promptly to determine whether the occlusion is suitable for treatment.
• Suspected Large-Vessel Occlusion (LVO): Do not delay urgent CTA / CT perfusion for a creatinine result. Address a known severe contrast reaction through the emergency imaging pathway.
• Coordinate imaging with IV thrombolysis preparation; additional studies should not delay otherwise indicated early treatment. AHA/ASA 2026 — Vascular Imaging.

• MRI-DWI: Infarct detection when CT is unrevealing or the diagnosis remains uncertain.
• DWI–FLAIR / Perfusion Mismatch: Selected unknown-onset or extended-window eligibility. Follow the specific imaging criteria. See Extended Windows.
• Persistent Deficit Despite Negative DWI: Continue stroke assessment, review the vascular imaging, and discuss repeat MRI when appropriate. Do not relabel an ongoing deficit as TIA merely because MRI is negative. Edlow 2017.

Evidence — MRI-Negative Stroke: A meta-analysis found negative DWI in approximately 6.8% of clinically diagnosed acute ischemic strokes, with higher odds in posterior-circulation disease. The proportion varies with the population and imaging timing; it is not a universal MRI miss rate. Edlow 2017.

• Confirm glucose before IV thrombolysis. Obtain CBC / platelets, electrolytes / renal function, and relevant coagulation studies.
• Routine platelet / coagulation results need not delay IVT when no abnormality is suspected; anticoagulant exposure or bleeding history changes the assessment. AHA/ASA 2026 — Laboratory Timing.
• Obtain ECG and troponin without delaying reperfusion; additional testing follows the suspected cause. AHA/ASA 2026 — Cardiac Testing.

• Within 4.5 Hours: Treat eligible disabling ischemic stroke promptly after hemorrhage exclusion and safety assessment.
• Explain potential functional benefit and serious bleeding risk to the patient / surrogate when feasible; document the decision without avoidable delay.
• Age over 80, a low NIHSS, or partial improvement does not independently exclude treatment. A truly nondisabling presentation follows a different pathway. AHA/ASA 2026 — IVT Decisions.

Evidence — Alteplase: Outcomes with no significant disability at three to six months occurred in 32.9% versus 23.1% with alteplase versus control within three hours, and 35.3% versus 30.1% at three to 4.5 hours. Early fatal intracranial hemorrhage increased; a 90-day mortality benefit was not established. These are trial averages, not individual predictions. Emberson 2014.

• Proximal Anterior Occlusion: Intracranial ICA / proximal MCA → immediate assessment; selected patients qualify through 24 hours.
• Large Core: Substantial established injury is not an automatic exclusion. Apply current imaging, timing, and baseline-function criteria.
• Basilar Occlusion: Urgent assessment within 24 hours; evidence is strongest in selected patients with NIHSS ≥10 and suitable imaging / baseline function. Lower scores require individualized assessment.
• Medium / Distal Occlusion: Do not extend proximal-vessel benefit to every clot. Selected dominant M2 disease differs from routine nondominant / distal occlusion treatment. AHA/ASA 2026 — EVT Selection.
• Transfer: Send imaging, timeline, examination, anticoagulant history, treatment doses / times, and BP trend. Do not wait for the alteplase infusion to finish.

Evidence — HERMES: NNT 2.6 for improvement by at least one modified Rankin Scale category—not one death prevented or one additional independent survivor. Goyal 2016.

• 220/120 is a threshold for considering intervention—not a treatment target or required minimum. Correct hypotension and assess new deficits during BP reduction.
• ACS, acute heart failure, aortic dissection, or another hypertensive emergency changes the plan. Do not automatically restart antihypertensives at 24 hours regardless of the clinical course. AHA/ASA 2026 — BP.
• After Successful EVT: Do not routinely force SBP below 140. Avoid hypotension and excessive variability; follow the specialist's reperfusion-specific instructions. AHA/ASA 2026 — Post-EVT BP.

Evidence — Post-EVT BP: OPTIMAL-BP found worse functional outcomes with a uniform SBP target below 140. HOPE found better recovery with reperfusion-guided targets in selected patients. Different populations, exclusions, and protocols do not establish one universally appropriate lower target. OPTIMAL-BP 2023 · HOPE 2026.

• Labetalol: 10–20 mg IV over one to two minutes; may repeat once when appropriate for heart rate / cardiopulmonary status.
• Nicardipine: 5 mg/hour IV, increasing by 2.5 mg/hour every 5–15 minutes, maximum 15 mg/hour. Titrate to the applicable target and repeat the neurologic examination. Stroke Nebraska — BP Regimens.

• Swallowing: Nothing by mouth, including oral medication, until swallowing safety is assessed; use an appropriate nonoral route when needed. AHA/ASA 2026 — Dysphagia.
• Glucose: Correct hypoglycemia; for persistent hyperglycemia, 140–180 mg/dL is reasonable with close monitoring.
• Fever: Treat and assess for infection or another cause. AHA/ASA 2026 — Glucose / Temperature.

Evidence — SHINE: Intensive glucose control did not improve function and increased severe hypoglycemia. Johnston 2019.

• Aspirin: After hemorrhage exclusion and the reperfusion decision, start within 24–48 hours when appropriate; initial oral dosing commonly 160–325 mg, with a nonoral route when swallowing is unsafe. Aspirin does not replace indicated reperfusion. AHA/ASA 2026 — Antiplatelets.
• Dual Antiplatelet Therapy (DAPT): Selected minor noncardioembolic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4), without IVT and with acceptable bleeding risk → aspirin + clopidogrel early, preferably within 24 hours, for 21 days, then single-agent therapy.
• Use the protocol-specified loading regimen; usual maintenance is aspirin 81 mg daily + clopidogrel 75 mg daily. Record the transition date. Expanded eligibility in selected atherosclerotic disease requires its specific criteria. AHA/ASA 2026 — DAPT.
• After IVT: Generally withhold antithrombotics until 24 hours after treatment, with follow-up CT / MRI before initiation; exceptional indications require specialist direction. AHA/ASA 2026 — Post-IVT Care.
• Anticoagulation: Therapeutic heparin is not routine acute arterial-stroke treatment. AF-related secondary prevention requires a separate timing decision based on infarct burden, hemorrhage risk, and treatment; DAPT is not an equivalent substitute. AHA/ASA 2026.
• ABCD2 is used here to describe a studied treatment population—not to decide discharge on its own.

Evidence — DAPT: CHANCE/POINT found most benefit within 21 days. ARAMIS supported DAPT in selected minor, nondisabling stroke; it does not support withholding IVT from every low-NIHSS patient. Pan 2019 · ARAMIS 2023.

• Cardioembolic: ECG / telemetry; selected echo for structural disease, thrombus, or endocarditis.
• Large-Artery: Review head / neck imaging for relevant stenosis or dissection; symptomatic carotid disease needs urgent specialist assessment.
• Small-Vessel: Match the syndrome to imaging; avoid assuming the mechanism from symptoms alone.
• Connect the cause to antithrombotic choice, lipid therapy, risk-factor treatment, and follow-up. Broad etiologic testing must not delay reperfusion. AHA 2023 — Mechanism / Prevention.

• Obtain brain / vascular assessment and ECG; MRI-DWI ideally within 24 hours. When MRI is unavailable, arrange timely imaging through observation, admission, transfer, or an established outpatient pathway.
• Assess relevant stenosis, dissection, AF, and other supported mechanisms. Begin appropriate prevention once hemorrhage and treatment conflicts are excluded.
• Low ABCD2 or negative DWI does not establish safe discharge. Recurrent events, abnormal vascular imaging, and follow-up access change the plan.
• A relevant acute infarct despite symptom resolution is ischemic stroke, not “TIA with infarction.” Recurrent active deficits re-enter the stroke pathway. See TIA Versus Stroke and Disposition. AHA 2023 — TIA Assessment.

• Repeat the deficit, consciousness, BP, glucose, and breathing. Confirm outstanding reperfusion decisions and support needs.
• After IVT: Neurologic / BP checks every 15 minutes for two hours, every 30 minutes for six hours, then hourly through 24 hours. Defer unnecessary invasive procedures when safe. AHA/ASA 2026 — Monitoring.
• New Headache / Vomiting / Neurologic Worsening: Emergency CT and stroke-team reassessment; stop ongoing alteplase. Tenecteplase has already been administered as a bolus.
• Suspected Thrombolytic Bleeding: CBC, coagulation studies, fibrinogen, type / cross, and immediate reversal-protocol / specialist activation. AHA/ASA 2026 — Bleeding.
• Tongue / Oropharyngeal Swelling: Assess progression, summon airway expertise, and stop ongoing alteplase. Follow the thrombolytic-angioedema pathway. AHA/ASA 2026 — Angioedema.
• Declining Consciousness / Large Infarct: Assess edema, mass effect, or hydrocephalus; urgent neurocritical / neurosurgical evaluation. See the separate Intracranial Hemorrhage and Airway pathways.

• Selected TIA presentations with sustained resolution, reassuring completed initial assessment, prevention started, and a secured rapid pathway.
• Arrange indicated testing and a definite TIA / neurology appointment, preferably within 48 hours. Confirm medication access, transport, and ability to return; recurrent focal symptoms require immediate EMS activation. AHA 2023 — Disposition.

• Ischemic stroke requiring stroke-unit assessment, telemetry, neurologic surveillance, swallowing / rehabilitation assessment, or urgent investigation.
• Acute infarction despite resolved symptoms: Ischemic stroke requiring monitored stroke assessment—not a TIA discharge branch.
• TIA: Recurrent symptoms, relevant stenosis, concerning cardiac findings, or an unsafe outpatient plan. Structured observation may complete evaluation in selected patients.
• Post-IVT care requires a stroke unit or ICU capable of the mandated monitoring. Transfer immediately when necessary reperfusion / stroke care is unavailable. AHA/ASA 2026 — Stroke Care.

• Airway / ventilatory failure, hemodynamic instability, or intensive titrated support.
• Symptomatic intracranial hemorrhage, major treatment-related bleeding, or airway-threatening angioedema.
• Deteriorating neurologic status, substantial edema / mass effect, hydrocephalus, or need for neurocritical / neurosurgical access. Level of care follows support and monitoring needs—not the treatment label alone. AHA/ASA 2026.