Acute Ischemic Stroke - Neurology Pathway (AHA/ASA 2024)

Algorithm Steps

1. ▶

   Start

   Acute Stroke Suspected

   Sudden neurologic deficit

   1. ⚠

      Warning

      Activate Stroke Code

      TIME IS BRAIN

      • IMMEDIATE ACTIONS:
      • - Note LAST KNOWN WELL (LKW) time
      • - ABCs, IV access, O2 if needed
      • - Point-of-care glucose (rule out hypoglycemia)
      • - NIHSS assessment
      • - STAT CT head (no contrast)
      • - Labs: CBC, BMP, coags, troponin
      • GOAL: Door to CT <25 min
      1. ◆

         Decision

         CT Head Results

         Hemorrhage vs ischemic

         1. ⚠

            Warning

            Hemorrhagic Stroke

            DIFFERENT MANAGEMENT

            • tPA CONTRAINDICATED
            • Neurosurgery consult
            • BP management (target <140 for ICH)
            • Reverse anticoagulation if applicable
            • Consider EVD if hydrocephalus
            • Follow ICH-specific guidelines
         2. ●

            Action

            Ischemic Stroke (No hemorrhage)

            Assess for reperfusion therapy

            • Check TIME from LKW:
            • - <4.5 hours: tPA candidate
            • - <24 hours: Thrombectomy candidate (LVO)
            • Check NIHSS
            • Review contraindications
            1. ◆

               Decision

               Within tPA Window? (<4.5 hours)

               From last known well

               1. ●

                  Action

                  tPA Contraindications

                  Review before giving

                  • ABSOLUTE:
                  • - Active internal bleeding
                  • - Recent intracranial hemorrhage
                  • - Intracranial neoplasm, AVM, aneurysm
                  • - Recent intracranial/spinal surgery
                  • - BP >185/110 despite treatment
                  • - Platelets <100,000
                  • - INR >1.7 or PTT >40
                  • - Current anticoagulation (DOACs <48h)
                  • RELATIVE (extended window 3-4.5h):
                  • - Age >80
                  • - NIHSS >25
                  • - Prior stroke + diabetes
                  1. ●

                     Action

                     tPA Administration

                     Alteplase protocol

                     • BEFORE tPA:
                     • - BP must be <185/110
                     • - Labetalol or nicardipine if needed
                     • ALTEPLASE DOSING:
                     • - 0.9 mg/kg (MAX 90 mg total)
                     • - 10% as IV bolus over 1 min
                     • - Remaining 90% infusion over 60 min
                     • POST-tPA:
                     • - ICU/stroke unit
                     • - Neuro checks q15 min
                     • - BP <180/105 x 24h
                     • - No anticoagulation/antiplatelets x 24h
                     • - Repeat CT at 24h or if decline
                     1. ●

                        Action

                        Large Vessel Occlusion (LVO) Assessment

                        For thrombectomy consideration

                        • GET CTA head/neck (or MRA)
                        • LVO LOCATIONS:
                        • - ICA (internal carotid)
                        • - M1/M2 (middle cerebral artery)
                        • - Basilar artery
                        • CLINICAL PREDICTORS:
                        • - NIHSS ≥6
                        • - Gaze deviation
                        • - Hemiplegia
                        • SCREENING SCALES:
                        • - RACE, LAMS, VAN
                        1. ●

                           Action

                           Mechanical Thrombectomy

                           For LVO within time window

                           • STANDARD WINDOW (0-6 hours):
                           • - LVO confirmed
                           • - NIHSS ≥6
                           • - ASPECTS ≥6
                           • - Pre-stroke mRS 0-1
                           • EXTENDED WINDOW (6-24 hours):
                           • - Based on perfusion imaging
                           • - DAWN or DEFUSE 3 criteria
                           • - Mismatch between core and penumbra
                           • CAN BE GIVEN WITH OR AFTER tPA
                           • Transfer to thrombectomy center if needed
                           1. ●

                              Action

                              Supportive Care

                              All acute stroke patients

                              • BP MANAGEMENT:
                              • - If no reperfusion: Permissive HTN <220/120
                              • - Post-tPA: <180/105 x 24h
                              • GLUCOSE: 140-180 mg/dL
                              • TEMPERATURE: Avoid hyperthermia
                              • DVT PROPHYLAXIS: SCDs, then heparin
                              • SWALLOW EVALUATION before PO
                              • ASPIRIN: 325mg within 24-48h (if no tPA)
                              • STATIN: High-intensity
                              1. ●

                                 Action

                                 Secondary Prevention Workup

                                 Determine etiology

                                 • IMAGING:
                                 • - MRI brain (if not done)
                                 • - Carotid imaging (CTA, MRA, or US)
                                 • - Echo (TTE ± TEE)
                                 • MONITORING:
                                 • - Telemetry ≥24h for AF detection
                                 • - Extended monitoring if cryptogenic
                                 • LABS:
                                 • - HbA1c, lipid panel
                                 • - Consider hypercoag workup if young
                                 1. ✓

                                    Outcome

                                    Outcomes

                                    Prognosis

                                    • tPA: 30% more likely to have minimal disability
                                    • Thrombectomy: NNT ~3 for functional independence
                                    • Time is brain: 1.9M neurons lost per minute
                                    • Door to needle goal: <60 min
                                    • Door to puncture goal: <90 min