Acute Stroke Suspected
Sudden neurologic deficit
All Pathways
NeurologyEmergency
Acute Ischemic Stroke - Neurology Pathway (AHA/ASA 2024)
Acute Ischemic Stroke - Neurology Pathway (AHA/ASA 2024): Acute Stroke Suspected → Activate Stroke Code → CT Head Results → Hemorrhagic Stroke.
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Warning 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
03Decision CT Head Results
Hemorrhage vs ischemic
04Warning 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
05Action 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
06Decision Within tPA Window? (<4.5 hours)
From last known well
07Action 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
08Action 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
09Action 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
10Action 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
11Action 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
12Action 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
13Outcome 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
- Path rejoins step 11Shared downstream outcome
- Path rejoins step 09Shared downstream outcome
- Path rejoins step 09Shared downstream outcome
Guideline Source
AHA/ASA Guidelines for Early Management of Acute Ischemic Stroke
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Time-dependent treatment windows
- Hemorrhagic stroke requires different management
- Thrombectomy requires specialized center
- NIHSS may underestimate posterior circulation stroke
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Acute Ischemic Stroke - Neurology Pathway (AHA/ASA 2024)?
The Acute Ischemic Stroke - Neurology Pathway (AHA/ASA 2024) is a emergency clinical algorithm for Neurology. It provides a structured decision tree to guide clinical decision-making, based on AHA/ASA Guidelines for Early Management of Acute Ischemic Stroke.
What guideline is the Acute Ischemic Stroke - Neurology Pathway (AHA/ASA 2024) based on?
This algorithm is based on AHA/ASA Guidelines for Early Management of Acute Ischemic Stroke (DOI: 10.1161/STR.0000000000000211).
What are the limitations of the Acute Ischemic Stroke - Neurology Pathway (AHA/ASA 2024)?
Known limitations include: Time-dependent treatment windows; Hemorrhagic stroke requires different management; Thrombectomy requires specialized center; NIHSS may underestimate posterior circulation stroke. Individual patient factors may require deviation from these recommendations.
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