Ischemic Stroke · Acute Care & Prevention

First-Pass Recognition

Stroke Until Proven Otherwise

The first clinical question is not "what is the final diagnosis?" — it's "could reperfusion still save brain?" Use BE-FAST publicly, NIHSS for triage, and CTA for vessels.

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Code Stroke trigger

Sudden face droop, arm weakness, speech/language change, vision loss, neglect, gait ataxia, gaze deviation, severe dizziness with focal signs, or decreased consciousness should immediately activate stroke protocol. Always check fingerstick glucose — hypoglycemia is the most common stroke mimic. Document last-known-well time, not discovery time.

B

Balance Sudden ataxia, vertigo with focal signs, drop attacks

E

Eyes Visual loss, hemianopia, diplopia, gaze deviation

F

Face Asymmetric droop, especially nasolabial fold flattening

A

Arm Drift on outstretched arms test, hemiparesis

S

Speech Slurred, expressive aphasia, receptive aphasia

T

Time Last-known-well clock starts. Call 911 / activate code

Mimics

Rule out the dangerous lookalikes

Hypoglycemia (always glucose first), seizure with Todd paralysis, complex migraine, conversion disorder, hypertensive encephalopathy, posterior reversible encephalopathy syndrome (PRES), Bell palsy, vestibular neuritis, peripheral nerve palsy, mass lesion, infection.

LVO clues

Cortical signs flag big-vessel

Aphasia, hemineglect, forced gaze deviation, hemianopia, dense face/arm/leg weakness, decreased consciousness, or NIHSS ≥6 raise suspicion for proximal anterior LVO. Use LAMS, RACE, or VAN scales prehospital.

Posterior

Don't miss vertebrobasilar

Diplopia, dysarthria, dysphagia, dizziness/vertigo, dysmetria, drop attacks ("the 5 Ds"), crossed signs, cranial neuropathies. Basilar occlusion can present as fluctuating consciousness, locked-in, or coma.

Last known well

The clock starts at LKW, not discovery

Wake-up and unknown-onset strokes may still be treatable using DWI–FLAIR mismatch (WAKE-UP trial) or perfusion mismatch criteria. Document anticoagulants, baseline mRS, and witnessed evolution carefully.

NIH Stroke Scale

NIHSS — The Universal Language of Stroke Severity

15 items, 0–42 points. Quantifies severity, predicts outcome, sets thresholds for IVT/EVT decisions and trials. Score is required documentation in every code stroke.

Item	Domain	Range	Notes
1a	Level of consciousness	0–3	Alert / drowsy / obtunded / coma
1b	LOC questions (month, age)	0–2	Both correct = 0; only intubation/aphasia exception
1c	LOC commands (eyes, hand)	0–2	Both correct = 0
2	Best gaze	0–2	Forced gaze deviation = 2 (LVO clue)
3	Visual fields	0–3	Confrontation; partial vs complete hemianopia vs bilateral
4	Facial palsy	0–3	Minor / partial / complete paralysis
5a / 5b	Motor arm L / R	0–4 each	Drift < 10 sec = 1; falls to bed = 4
6a / 6b	Motor leg L / R	0–4 each	Drift < 5 sec = 1; falls immediately = 4
7	Limb ataxia	0–2	Finger-to-nose, heel-to-shin out of proportion to weakness
8	Sensory	0–2	Pinprick
9	Best language (aphasia)	0–3	Picture description, naming, reading
10	Dysarthria	0–2	Articulation, separate from aphasia
11	Extinction / inattention (neglect)	0–2	Visual + tactile

0–4

Minor stroke

Often non-disabling. AHA/ASA 2026 prefers DAPT over IVT when truly non-disabling. But beware: aphasia or dominant-hand weakness with NIHSS 3 is still disabling.

5–15

Moderate stroke

Most patients eligible for IVT if within window. Watch for LVO clues — aphasia, neglect, gaze deviation. Get CTA if not already obtained.

≥16

Severe / disabling

Strong predictor of LVO. Mortality and disability rise sharply. EVT pathway should be activated reflexively for anterior circulation; basilar with NIHSS ≥10 + symptoms ≤24 h is a strong EVT recommendation per AHA/ASA 2026.

Reperfusion Windows

Time-Based Treatment Map

Five windows, five decision frames. Real treatment requires institutional protocol, contraindication screening, vessel imaging, and stroke specialist input. Tissue beats clock when imaging selects.

0–4.5h

IV Thrombolysis

Eligible disabling AIS: alteplase 0.9 mg/kg (max 90 mg) or tenecteplase 0.25 mg/kg (max 25 mg). AHA/ASA 2026 endorses both as Class I.

4.5–9h

Selected IVT

Wake-up & unknown-onset stroke: DWI–FLAIR mismatch (WAKE-UP) or perfusion mismatch (EXTEND, EPITHET) can identify candidates beyond standard window.

0–6h

Anterior LVO EVT

Standard-window mechanical thrombectomy for ICA, M1, proximal M2, ACA. IVT is given concurrently if eligible — do not skip bridging IVT to "save time."

6–24h

Late-Window EVT

Anterior LVO with imaging selection: DAWN (clinical–core mismatch) or DEFUSE 3 (perfusion mismatch). 2026 expands to large core patients (RESCUE-Japan LIMIT, SELECT2, ANGEL-ASPECT).

≤24h

Basilar EVT

2026 strong recommendation: EVT for basilar occlusion within 24 h with NIHSS ≥10 (ATTENTION, BAOCHE trials).

Reperfusion Atlas · AHA/ASA 2026

Pick the Clinical Frame

Six high-yield decision frames. Each maps the question, the action, and the trap. Use the drug-dose cards below for exact IVT regimens, BP/glucose guardrails, and absolute contraindications.

Acute Stroke Decision Frames

Disabling Deficit Within 4.5 Hours

The core decision: is the deficit disabling, is hemorrhage excluded on NCCT, are contraindications absent, can BP be controlled to <185/110, and are we within the 4.5-hour window?

Drug Choice AHA/ASA 2026 Class I: alteplase 0.9 mg/kg (max 90 mg, 10% bolus + 90% over 60 min) OR tenecteplase 0.25 mg/kg (max 25 mg, single bolus over 5 sec).

Don't Delay If standard NCCT and clinical eligibility are clear, do NOT delay IVT for additional multimodal imaging. Time is brain — every 15 min loses ~4% of good outcomes.

BP Guardrail BP <185/110 before IVT (labetalol 10–20 mg IV, nicardipine drip). After IVT: <180/105 × 24 h. Don't lower SBP <140 — no benefit, possible harm.

Alteplase tPA · 4.5h window

Dose: 0.9 mg/kg · max 90 mg total

Bolus: 10% over 1 min · Infusion: 90% over 60 min

Fibrin-specific recombinant tPA. Continuous infusion is operationally complex but the historical standard. Half-life ~5 min. Monitor neuro exam q15min × 2 h, then q30min × 6 h, q1h × 16 h.

Tenecteplase TNK · 4.5h window

Dose: 0.25 mg/kg · max 25 mg total

Single IV bolus over 5 seconds · no infusion

2026 Class I as alternative to alteplase. Higher fibrin specificity, longer half-life (~20 min), single bolus simplifies workflow — particularly for transfers. Avoid 0.40 mg/kg dose (worse outcomes per NOR-TEST 2A). FDA TNKase label specifies AIS initiation within 3 h.

Blood Pressure

Pre-IVT Lower BP to < 185/110 mmHg before bolus (labetalol 10–20 mg IV; nicardipine drip).
Post-IVT Maintain < 180/105 mmHg × 24 h.
Not for IVT/EVT Permissive HTN up to ≤ 220/120 mmHg in first 24–48 h.
2026 update Do NOT lower SBP intensively to < 140 after IVT or EVT — no benefit, possible harm.

Glucose

Hypoglycemia Always check FSG; correct < 60 mg/dL immediately (D50W).
Hyperglycemia Treat persistent > 180 mg/dL with insulin.
Avoid Intensive 80–130 mg/dL targets — increase severe hypoglycemia (SHINE trial).
Goal Reasonable target 140–180 mg/dL in AIS.

Other Acute Care

Temp Treat fever > 38°C (acetaminophen). Hyperthermia worsens outcome.
DVT prophylaxis IPC immediately; LMWH/UFH after 24 h if no IVT or after follow-up imaging.
Dysphagia Bedside swallow screen before any oral intake or meds — including aspirin.
Antiplatelet Aspirin 160–325 mg within 24–48 h; hold 24 h after IVT until follow-up CT.

IVT Absolute & Relative Contraindications

ICH on imaging — any acute hemorrhage

Active internal bleeding — including GI in last 21 days

Recent major surgery — within 14 days

Recent ischemic stroke — within 3 months

Severe head trauma — within 3 months

Recent intracranial/spinal surgery

Suspected SAH or aortic dissection

BP uncontrolled > 185/110 despite treatment

Platelets < 100,000 · INR > 1.7 · aPTT > 40 sec

DOAC within 48 h (unless reversed; idarucizumab for dabigatran)

Glucose < 50 mg/dL until corrected

Infective endocarditis — high ICH risk

Case Cockpit · Convert Data → Action

Scenario-Based Clinical Reasoning

Pick a presentation. The pathway updates with the actions, the dose, the trap, and the "do-not-miss" pearl. Pillars on the right are the constants in every plan.

Clinical scenario

Hyperacute Disabling MCA Syndrome (NIHSS 14)

Activate stroke team immediately. Document LKW, glucose, BP, baseline mRS, anticoagulant use, and complete NIHSS in <5 min.
Noncontrast CT to exclude hemorrhage; CTA simultaneously to identify LVO. Don't delay eligible IVT for extra multimodal imaging.
If eligible: tenecteplase 0.25 mg/kg (max 25 mg) single IV bolus OR alteplase 0.9 mg/kg (max 90 mg). Lower BP <185/110 first if needed.
If LVO confirmed: mobilize EVT in parallel with bridging IVT. Door-to-puncture target ≤60 min for transfers.
Admit to stroke unit; bedside swallow screen before any oral intake; DVT prophylaxis with IPC immediately, pharmacologic after follow-up CT.

Identify

Last-known-well + NIHSS + glucose

The clock starts at LKW. Get NIHSS in <5 min. Always check glucose — hypoglycemia is the most common stroke mimic.

Image

NCCT first, then CTA / perfusion

Noncontrast CT excludes hemorrhage. CTA finds the artery. CT perfusion or MRI extends windows when LKW is uncertain or >6 h.

Treat

IVT and/or EVT — don't choose, combine

If both eligible, give bridging IVT and mobilize EVT. BP < 185/110 before IVT, < 180/105 after.

Plan

Mechanism → secondary prevention

Stroke unit, swallow screen, AFib monitoring (≥30 d if cryptogenic), antithrombotic by mechanism, BP/lipid/glucose targets, rehab.

Mechanism · TOAST Classification

Classify the Stroke to Prevent the Next One

Secondary prevention is mechanism-specific: artery, heart, small vessel, other determined cause, or still cryptogenic after a real workup. The discharge plan tells the story of why this happened.

LAA · 20–25%

Large Artery Atherosclerosis

Extracranial carotid, intracranial stenosis, aortic arch atheroma. Stenosis ≥50% with territory-matched infarct. Severe symptomatic carotid → CEA or stenting within 2 weeks. High-intensity statin; aspirin or clopidogrel.

CE · 20–25%

Cardioembolic

AF/flutter, LV thrombus, cardiomyopathy with EF <35%, mechanical valve, infective endocarditis, recent MI, PFO. Anticoagulation when safe — usually DOAC for non-valvular AF; warfarin for mechanical valve and antiphospholipid syndrome.

SVD · ~25%

Small Vessel Disease (Lacunar)

Classic lacunar syndromes (pure motor, pure sensory, ataxic hemiparesis, dysarthria-clumsy hand, sensorimotor). Linked to HTN, DM, smoking, OSA, dyslipidemia. Antiplatelet + aggressive risk factor control.

OTH · ~5%

Other Determined Cause

Cervical artery dissection (young, neck pain/trauma), vasculitis (PACNS, GCA), antiphospholipid, sickle cell, hypercoagulable state, malignancy (Trousseau), CADASIL, Fabry, MELAS, illicit drugs (cocaine, amphetamines).

ESUS · ~17%

Embolic Stroke of Undetermined Source

Non-lacunar infarct with no LAA ≥50%, no high-risk cardioembolic source, no other cause. Do NOT empirically anticoagulate — NAVIGATE-ESUS and RE-SPECT ESUS were negative. Pursue prolonged cardiac monitoring (≥30 days) for AF.

TIA

TIA — A Warning Shot, Not a Diagnosis

Tissue-based definition (no infarct on imaging). ABCD² + DWI for risk stratification. ~10–20% have a stroke within 90 days, half within 48 h. Urgent vessel imaging, antithrombotic, risk-factor control, follow-up. CHANCE/POINT: 21-day DAPT for high-risk TIA (ABCD² ≥4 or NIHSS ≤3).

Secondary Prevention

The Discharge Plan Is a Second Emergency

Stroke recurrence prevention is not one prescription. It's mechanism, targets, adherence, and social reality. The first 90 days carry the highest risk — design the plan to hold.

Antithrombotic

Choose by mechanism

Most ischemic stroke survivors need antithrombotic therapy. Non-cardioembolic → antiplatelet (aspirin 81 mg, clopidogrel 75 mg, or aspirin+dipyridamole). AF → DOAC (apixaban, rivaroxaban, edoxaban, dabigatran) when safe.

DOAC for non-valvular AF

DAPT

Short, selected, not forever

Aspirin + clopidogrel for 21 days after high-risk TIA or minor stroke (CHANCE, POINT). Aspirin + ticagrelor in CHANCE-2 (CYP2C19 LOF carriers). For severe symptomatic intracranial stenosis: 90 days DAPT (SAMMPRIS). Long-term DAPT generally avoided.

21-day DAPT (CHANCE/POINT)

Targets

BP & LDL targets

BP < 130/80 mmHg for most patients (SPS3, ESC 2024). High-intensity statin (atorvastatin 80 mg or rosuvastatin 20–40 mg). LDL-C goal < 70 mg/dL; consider ezetimibe ± PCSK9 inhibitor if not at goal.

BP <130/80 · LDL <70

Carotid & Procedures

Don't miss treatable stenosis

Symptomatic extracranial carotid stenosis 50–99% after non-disabling stroke or TIA → CEA or CAS, ideally within 2 weeks. PFO closure for cryptogenic stroke age <60 with high-risk PFO (CLOSE, REDUCE, RESPECT, DEFENSE-PFO trials).

CEA within 14 d

Lifestyle

Mediterranean & movement

Mediterranean or DASH dietary pattern, ≥150 min/week moderate aerobic activity, smoking cessation, sleep apnea screening + CPAP, weight management, alcohol moderation, optimized diabetes care (HbA1c <7% in most).

150 min / wk activity

Equity

Social determinants are clinical

2024 AHA primary prevention guideline emphasizes screening for and addressing health-related social needs: medication access, transportation, food security, housing, literacy. Adherence engineering matters more than another prescription.

Screen SDOH

AF + Acute Stroke — When to Start Anticoagulation? (1–3–6–12 Day Rule)

Timing depends on infarct size and hemorrhagic transformation risk. ESO consensus / ELAN trial (2023) supports earlier initiation than the historical "wait 14 days" approach. Always confirm no hemorrhagic transformation on follow-up imaging.

Day 1

TIA No infarct → start anticoagulation immediately once neurology/imaging confirms.

Day 3

Small infarct Non-disabling, NIHSS <8. Start by day 3–4 after follow-up CT.

Day 6

Moderate infarct NIHSS 8–15. Anticoagulation typically by day 6–7 if no hemorrhagic transformation.

Day 12

Large infarct NIHSS >15 or large territory. Wait ≥12–14 days; some guidelines individualize further.

Stroke Systems & Policy

Stroke Care Is a Protocol Sport

Good clinicians use systems: EMS triage, mobile stroke units, transfer protocols, time targets, and continuous audit loops. The 2026 AHA/ASA guideline is as much about systems as it is about drugs.

EMS Routing

Closest EVT-capable hospital

2026 endorses considering local system performance and direct transport to the nearest EVT-capable center for suspected LVO when rapid interhospital transfer is unreliable. Use validated prehospital LVO scales (LAMS, RACE, VAN).

Direct triage if LVO

Mobile Stroke Unit

Ambulance with CT + tPA

2026 endorses mobile stroke units (MSUs) — ambulance-based units with onboard CT and capability for prehospital thrombolysis — in well-organized systems. Reduce time-to-treatment by 30+ minutes.

Prehospital tPA

Target: Stroke III

Door-to-needle & door-to-device

DTN ≤60 min in ≥85% of eligible IVT patients; ≤45 min in ≥75%; ≤30 min in ≥50%. Door-to-device ≤90 min for direct-arriving EVT (≤60 min for transfers) in ≥50%.

DTN ≤60 in ≥85%

Transfer Discipline

Door-in / door-out

Interhospital transfer agreements must prioritize acute stroke. Goal: door-in/door-out ≤90 min for transfers to EVT-capable centers. Drip-and-ship with bridging IVT remains the dominant U.S. model.

DI/DO ≤90 min

Pediatrics

First-ever pediatric AIS recommendations

2026 includes the first AHA/ASA recommendations for childhood AIS: early recognition, selected IVT (alteplase safety data; efficacy uncertain), EVT in selected pediatric patients with LVO, post-stroke dysphagia treatment.

New in 2026

Quality Loop

Debrief every miss

Track LKW capture, door-to-CT, door-to-needle, door-to-puncture, hemorrhage complications, secondary prevention at discharge, 90-day mRS, and TICI reperfusion grade. Get With The Guidelines–Stroke is the U.S. registry.

GWTG-Stroke

Active Recall · 12 Questions

Board-Style Micro Quiz

Twelve high-yield questions across recognition, IVT/EVT decisions, AHA/ASA 2026 updates, mechanism, and secondary prevention. Streak counter, badges, immediate teaching pearl after every answer.

Question 1 of 12

Streak: 0

According to AHA/ASA 2026, which thrombolytic options are endorsed (Class I) within the 4.5-hour window for eligible disabling AIS?

?

Choose an answerThe teaching pearl will appear here.

Evidence Base · Verified April 2026

Guidelines & Pivotal Trials

This tool summarizes, simplifies, and teaches — it does not reproduce full guidelines. Always defer to current institutional protocols and the latest published versions before clinical decisions.

AHA/ASA 2026 Acute Ischemic Stroke Guideline Prabhakaran S, Gonzalez NR, Zachrison KS, et al. Stroke 2026. Replaces 2018/2019 guidelines. Key changes: tenecteplase as Class I, basilar EVT ≤24h NIHSS≥10, large core EVT, mobile stroke units, first pediatric AIS recommendations, less aggressive BP/glucose targets. Read source

AHA/ASA 2026 Top Things to Know Concise practice-change summary for the 2026 acute ischemic stroke guideline. Read source

AHA/ASA 2021 Secondary Prevention Guideline Mechanism-based prevention after ischemic stroke or TIA: antithrombotics, AF, carotid disease, intracranial stenosis, PFO, ESUS, lifestyle. Read source

AHA/ASA 2024 Primary Prevention Guideline Life-course prevention, social determinants of health, Mediterranean/DASH diet, GLP-1 RA in selected high-risk patients, sex-specific risks. Read source

NICE NG128 — Stroke & TIA Management UK NICE acute stroke and TIA diagnosis and management guideline. Last reviewed 2026. Read source

ESO Tenecteplase Expedited Recommendation European Stroke Organisation: tenecteplase 0.25 mg/kg as alternative to alteplase within 4.5 h. Avoid 0.40 mg/kg dose. Read source

FDA TNKase Prescribing Information (2025) U.S. label: tenecteplase indicated for adult AIS, single IV bolus over 5 sec, max AIS dose 25 mg, initiate within 3 h of symptom onset. Read source

DAWN & DEFUSE 3 — Late-Window EVT Trials establishing 6–24h EVT for anterior LVO with clinical–core (DAWN) or perfusion (DEFUSE 3) mismatch. NEJM 2018. Read source

SELECT2, RESCUE-Japan LIMIT, ANGEL-ASPECT — Large Core EVT 2022–2023 trials supporting EVT benefit even in large ischemic core (low ASPECTS) — basis for 2026 expanded eligibility. Read source

ATTENTION & BAOCHE — Basilar EVT Trials establishing benefit of EVT for basilar artery occlusion within 24 h, supporting 2026 strong recommendation when NIHSS ≥10. Read source

CHANCE / POINT / CHANCE-2 — Short-term DAPT 21-day aspirin + clopidogrel (or ticagrelor in CYP2C19 LOF) after high-risk TIA or minor stroke. NEJM 2013, 2018, 2021. Read source

ELAN Trial — AF Anticoagulation Timing Earlier vs later DOAC initiation after stroke in AF. Earlier was non-inferior. Supports the 1-3-6-12 day approach. Read source

WAKE-UP & EXTEND — Extended-Window IVT DWI-FLAIR mismatch (WAKE-UP) and perfusion mismatch (EXTEND) for unknown-onset and 4.5–9h IVT. NEJM 2018, 2019. Read source

SHINE — AIS Glucose Management Intensive glucose control (80–130 mg/dL) did not improve outcome and increased hypoglycemia. JAMA 2019. Basis for 140–180 target. Read source

AHA Target: Stroke Phase III Quality improvement targets: DTN ≤60 min in ≥85%, ≤45 min in ≥75%, ≤30 min in ≥50%. Door-to-device targets for EVT. Read source

Joint Commission Stroke Measures Performance measures for stroke certification and accreditation programs (Primary, Comprehensive, Thrombectomy-capable). Read source