← Diagnosis and Management Guides
Acute Ischemic Stroke
Key considerations: Large vessel occlusion, Hemorrhagic stroke, Hypoglycemia mimicking stroke
Cannot miss
- Large vessel occlusion
- Hemorrhagic stroke
- Hypoglycemia mimicking stroke
- Todd paralysis
Likely diagnoses
- Ischemic stroke
- TIA
- Complex migraine
- Seizure with postictal weakness
Red flags
- NIHSS ≥6
- Large vessel occlusion on CTA
- Basilar artery occlusion
Workup
- history: Last known well time, symptom onset, prior strokes, anticoagulant use; exam: NIHSS, focused neurologic exam; labs: Glucose (STAT), CBC, BMP, coags, troponin; imaging: Non-contrast CT head (rule out hemorrhage); CTA head/neck (LVO screen); MRI DWI if diagnosis uncertain; bedside: NIHSS scoring, glucose check
Management
- immediate: IV alteplase if within 4.5hr window and eligible; Thrombectomy if LVO within 24hr (with perfusion imaging); BP management: permissive HTN <220/120 (or <185/110 if tPA candidate); general: Aspirin 325mg within 24-48hr (after tPA >24hr); Stroke unit admission; DVT prophylaxis; Swallow evaluation before PO
Disposition
- admit: All acute strokes to stroke unit or ICU; discharge: After stabilization with secondary prevention plan; consults: Neurology, neurointerventional if LVO
Clinical pearls
- Door-to-needle <60 min for tPA, door-to-groin <90 min for thrombectomy
- DAWN and DEFUSE-3 extended thrombectomy window to 24hr with perfusion mismatch
Source and review
- AHA/ASA Stroke Guidelines 2019. Last reviewed: 2024-11-01