Stroke / TIA

Key considerations: Large vessel occlusion (LVO), Hemorrhagic stroke (ICH), Basilar artery occlusion

Cannot miss

Large vessel occlusion (LVO)
Hemorrhagic stroke (ICH)
Basilar artery occlusion
Carotid dissection
Cerebral venous sinus thrombosis

Likely diagnoses

Ischemic stroke
Transient ischemic attack
Todd paralysis (post-seizure)
Hypoglycemia
Complex migraine with aura
Bell palsy (lower motor neuron facial only)

Red flags

Acute onset focal neurological deficit
Last known well within tPA/thrombectomy window
NIHSS ≥6 (LVO likely)
Posterior circulation symptoms: vertigo, diplopia, ataxia, dysarthria
Rapidly deteriorating neurological exam
Headache with focal deficits (hemorrhagic stroke)

Workup

history: Time of onset or last known well — critical for treatment decisions; Symptom progression or improvement; Medications: anticoagulants, antiplatelets; Prior stroke/TIA history; Risk factors: AFib, HTN, DM, smoking, CAD; Recent trauma (dissection risk); exam: NIHSS score — standardized stroke severity assessment; Facial droop: ask to smile and show teeth; Arm/leg weakness: drift testing; Speech: dysarthria (slurred) vs aphasia (language); Visual fields: homonymous hemianopia; Gaze deviation: toward lesion in large strokes; Posterior circulation: ataxia, nystagmus, vertigo, diplopia; labs: Point-of-care glucose — MUST be checked before tPA; CBC with platelets; BMP; Coagulation: PT/INR, aPTT; Troponin (cardiac source of embolism); HbA1c, lipid panel (not urgent but for workup); imaging: CT head non-contrast: rule out hemorrhage (FIRST — before any treatment); CT angiography head and neck: LVO detection, carotid stenosis, dissection; CT perfusion: mismatch for extended window thrombectomy (6-24 hours); MRI DWI: most sensitive for ischemia but should not delay treatment; bedside: Point-of-care glucose — hypoglycemia mimics stroke; NIHSS scoring — perform and document; 12-lead ECG: atrial fibrillation (embolic source)

Management

immediate: Establish last known well time; CT head immediately — rule out hemorrhage; Check glucose — treat hypoglycemia if present; Activate stroke team if within treatment window; general: IV tPA (alteplase): 0.9mg/kg (max 90mg), 10% bolus over 1 min, remainder over 60 min; Window: 0–4.5 hours from last known well (3-hour standard, 4.5 with criteria); Thrombectomy: LVO with NIHSS ≥6, within 24 hours with favorable imaging; BP management: allow permissive hypertension <220/120 if not receiving tPA; <185/110 if receiving tPA; specific: diagnosis: Ischemic Stroke (tPA Candidate); steps: Alteplase 0.9mg/kg IV (max 90mg); Admit to ICU/stroke unit — neuro checks q15min; BP <185/110 pre-tPA, <180/105 post-tPA; No anticoagulation or antiplatelets for 24 hours post-tPA; Repeat CT head at 24 hours; diagnosis: Large Vessel Occlusion; steps: IV tPA if within window, then proceed to thrombectomy; Transfer to thrombectomy-capable center if not available; Extended window (6-24 hours) with favorable CT perfusion (DAWN/DEFUSE-3); Do not delay transfer for tPA administration; diagnosis: Hemorrhagic Stroke; steps: Reverse anticoagulation immediately if applicable; BP target: SBP <140 (INTERACT2 trial); Neurosurgery consult for posterior fossa or large volume hemorrhage; ICU admission, close neuro monitoring; diagnosis: TIA; steps: ABCD2 score for risk stratification; Dual antiplatelet: aspirin + clopidogrel x21 days (POINT trial); Workup: carotid imaging, echo, Holter, lipids; TIA clinic follow-up within 24-48 hours

Disposition

admit: All acute strokes — stroke unit or ICU; Post-tPA patients to ICU for 24 hours; High-risk TIA (ABCD2 ≥4, recurrent, AFib); Hemorrhagic stroke — ICU with neurosurgery consult; discharge: Low-risk TIA with completed workup and close follow-up; Stroke mimic identified (migraine, hypoglycemia, Todd); consults: Neurology: all strokes and TIAs; Interventional neuroradiology: thrombectomy; Neurosurgery: hemorrhagic stroke, cerebellar stroke with hydrocephalus; Cardiology: AFib, PFO closure evaluation

Clinical pearls

Time is brain: 1.9 million neurons die every minute in untreated large vessel occlusion
CT head rules OUT hemorrhage — it does NOT rule IN ischemic stroke (early ischemic changes may not be visible)
Check glucose before tPA — hypoglycemia is a stroke mimic that is easily treated
Extended thrombectomy window: DAWN and DEFUSE-3 trials showed benefit up to 24 hours with favorable perfusion imaging
Bell palsy = lower motor neuron (entire half of face). Stroke = upper motor neuron (forehead spared)

Source and review

AHA/ASA Stroke Guidelines 2019, AHA/ASA tPA Eligibility 2019. Last reviewed: 2024-11-01