Suspected Acute Stroke
Sudden neurological deficit - activate stroke code
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Emergency MedicineEmergency
Acute Ischemic Stroke Management (AHA/ASA 2019)
Acute Ischemic Stroke Management (AHA/ASA 2019): Suspected Acute Stroke → Immediate Assessment → Non-Contrast CT Head → Hemorrhage on CT? → Hemorrhagic ...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action 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
03Action 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
04Decision Hemorrhage on CT?
Intracranial hemorrhage excludes thrombolysis
05Warning Hemorrhagic Stroke
Different management - see ICH algorithm
- Reverse anticoagulation if applicable
- Blood pressure control
- Neurosurgery consultation
- ICU admission
06Action 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
07Decision 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
08Decision 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
09Action 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
10Decision 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
11Action 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
12Action 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
13Action 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
14Outcome Good Outcome
mRS 0-2 at 90 days
15Outcome Disability/Death
Rehabilitation, goals of care discussion
- Path rejoins step 12Shared downstream outcome
16Action 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
- Path rejoins step 10Shared downstream outcome
- Path rejoins step 10Shared downstream outcome
Guideline Source
Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Time windows are strict - document exact symptom onset time
- tPA contraindications must be carefully reviewed
- Large vessel occlusion screening requires additional assessment
- Blood pressure targets differ for tPA-eligible vs non-eligible patients
- Does not cover posterior circulation stroke nuances
Contraindicated Populations
pediatric
Applicable Regions
USEUInternational
EU: ESO guidelines largely concordant; tenecteplase increasingly used
US: Follow AHA/ASA guidelines; Get With The Guidelines participation recommended
International: Thrombectomy may not be available in all centers
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Acute Ischemic Stroke Management (AHA/ASA 2019)?
The Acute Ischemic Stroke Management (AHA/ASA 2019) is a emergency clinical algorithm for Emergency Medicine. It provides a structured decision tree to guide clinical decision-making, based on Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines.
What guideline is the Acute Ischemic Stroke Management (AHA/ASA 2019) based on?
This algorithm is based on Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines (DOI: 10.1161/STR.0000000000000211).
What are the limitations of the Acute Ischemic Stroke Management (AHA/ASA 2019)?
Known limitations include: Time windows are strict - document exact symptom onset time; tPA contraindications must be carefully reviewed; Large vessel occlusion screening requires additional assessment; Blood pressure targets differ for tPA-eligible vs non-eligible patients; Does not cover posterior circulation stroke nuances. Individual patient factors may require deviation from these recommendations.
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