Acute Ischemic Stroke Management (AHA/ASA 2019)

Algorithm Steps

1. ▶

   Start

   Suspected Acute Stroke

   Sudden neurological deficit - activate stroke code

   1. ●

      Action

      Immediate Assessment

      ABCs, glucose, establish IV, time of onset

      • Determine LAST KNOWN WELL time (not when found)
      • Check blood glucose - treat if <60 or >400
      • Establish 2 large-bore IVs
      • 12-lead ECG
      • Activate stroke team/neurology
      1. ●

         Action

         Non-Contrast CT Head

         STAT - target door-to-CT <25 minutes

         • Rule out hemorrhage
         • Assess for early ischemic changes
         • Large hypodensity may contraindicate tPA
         • Consider CTA if LVO suspected
         1. ◆

            Decision

            Hemorrhage on CT?

            Intracranial hemorrhage excludes thrombolysis

            1. ⚠

               Warning

               Hemorrhagic Stroke

               Different management - see ICH algorithm

               • Reverse anticoagulation if applicable
               • Blood pressure control
               • Neurosurgery consultation
               • ICU admission
            2. ●

               Action

               Calculate NIHSS

               NIH Stroke Scale score

               • Score 1-4: Minor stroke
               • Score 5-15: Moderate stroke
               • Score 16-20: Moderate-severe
               • Score >20: Severe stroke
               • Document for tPA eligibility and LVO screening
               1. ◆

                  Decision

                  Symptom Onset ≤4.5 hours?

                  tPA time window assessment

                  • Standard window: 0-3 hours
                  • Extended window: 3-4.5 hours (additional criteria)
                  • Wake-up stroke: may qualify with perfusion imaging
                  1. ◆

                     Decision

                     tPA Contraindications?

                     Review absolute and relative contraindications

                     • ABSOLUTE: ICH history, recent surgery, active bleeding
                     • RELATIVE: BP >185/110, INR >1.7, platelets <100k
                     • 3-4.5hr additional: age >80, severe stroke, DM+prior stroke
                     1. ●

                        Action

                        IV Alteplase

                        0.9 mg/kg (max 90mg); 10% bolus, rest over 60min

                        • Target door-to-needle ≤60 minutes
                        • BP must be <185/110 before and <180/105 after
                        • No anticoagulants or antiplatelets for 24 hours
                        • Repeat NIHSS at 2hr and 24hr
                        • CT head at 24 hours before antiplatelets
                        1. ◆

                           Decision

                           Large Vessel Occlusion?

                           CTA or clinical suspicion

                           • NIHSS ≥6 suggests LVO
                           • Cortical signs (aphasia, neglect, gaze preference)
                           • CTA shows ICA, M1, or basilar occlusion
                           • Consider RACE, LAMS, or VAN screening
                           1. ●

                              Action

                              Mechanical Thrombectomy

                              For LVO within 24 hours (selected patients)

                              • Standard window: 0-6 hours from LKW
                              • Extended window 6-24hr: DAWN/DEFUSE-3 criteria
                              • Transfer to thrombectomy-capable center
                              • Do NOT delay tPA for transfer
                              • Target door-to-groin ≤90 minutes
                              1. ●

                                 Action

                                 Post-Treatment Care

                                 Stroke unit admission

                                 • Neuro checks q15min x 2hr, then q1hr x 6hr
                                 • BP monitoring per protocol
                                 • Dysphagia screening before oral intake
                                 • PT/OT/Speech evaluation
                                 • Secondary prevention workup
                                 1. ●

                                    Action

                                    Secondary Prevention

                                    Prevent recurrent stroke

                                    • Antiplatelets: ASA, clopidogrel, or DAPT
                                    • Statin: high-intensity (atorvastatin 80mg)
                                    • Atrial fibrillation: anticoagulation
                                    • Carotid stenosis: consider CEA/CAS
                                    • BP target <130/80 after acute phase
                                    1. ✓

                                       Outcome

                                       Good Outcome

                                       mRS 0-2 at 90 days

                                    2. ✓

                                       Outcome

                                       Disability/Death

                                       Rehabilitation, goals of care discussion

                     2. ●

                        Action

                        tPA Contraindicated

                        Document reason; proceed with other interventions

                        • Still evaluate for thrombectomy
                        • Aspirin 325mg within 24-48 hours
                        • Permissive HTN (up to 220/120)
                        • DVT prophylaxis