import json, subprocess, base64, sys
from io import BytesIO
from pptx import Presentation
from pptx.util import Inches, Pt, Emu
from pptx.dml.color import RGBColor
from pptx.enum.text import PP_ALIGN, MSO_ANCHOR
from pptx.util import Inches, Pt

# ── Colour palette ──────────────────────────────────────────────
NAVY      = RGBColor(0x0A, 0x3D, 0x62)   # deep navy – headers
TEAL      = RGBColor(0x00, 0x7A, 0x8A)   # teal – accent / section bars
ORANGE    = RGBColor(0xE5, 0x5A, 0x00)   # orange – highlights / keywords
WHITE     = RGBColor(0xFF, 0xFF, 0xFF)
LIGHT_BG  = RGBColor(0xF0, 0xF6, 0xFA)   # slide background
DARK_TEXT = RGBColor(0x1A, 0x1A, 0x2E)
MID_GRAY  = RGBColor(0x6C, 0x75, 0x7D)

prs = Presentation()
prs.slide_width  = Inches(13.333)
prs.slide_height = Inches(7.5)
blank = prs.slide_layouts[6]

# ── Helper: filled rectangle ─────────────────────────────────────
def add_rect(slide, x, y, w, h, fill_rgb, alpha=None):
    shape = slide.shapes.add_shape(1, Inches(x), Inches(y), Inches(w), Inches(h))
    shape.line.fill.background()
    shape.fill.solid()
    shape.fill.fore_color.rgb = fill_rgb
    return shape

# ── Helper: text box ─────────────────────────────────────────────
def add_text(slide, text, x, y, w, h, size, bold=False, color=DARK_TEXT,
             align=PP_ALIGN.LEFT, italic=False, wrap=True):
    tb = slide.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame
    tf.word_wrap = wrap
    tf.margin_left = 0; tf.margin_right = 0
    tf.margin_top = 0;  tf.margin_bottom = 0
    p = tf.paragraphs[0]
    p.alignment = align
    run = p.add_run()
    run.text = text
    run.font.name  = "Calibri"
    run.font.size  = Pt(size)
    run.font.bold  = bold
    run.font.italic = italic
    run.font.color.rgb = color
    return tb

# ── Helper: multi-bullet text box ────────────────────────────────
def add_bullets(slide, bullets, x, y, w, h, size=16, color=DARK_TEXT,
                bold_first=False, indent=False):
    tb = slide.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame
    tf.word_wrap = True
    tf.margin_left = 0; tf.margin_right = 0
    tf.margin_top = Pt(4); tf.margin_bottom = 0
    for i, b in enumerate(bullets):
        p = tf.add_paragraph() if i > 0 else tf.paragraphs[0]
        p.space_before = Pt(3)
        p.space_after  = Pt(2)
        prefix = "    \u2023 " if indent else "\u2022 "
        run = p.add_run()
        run.text = prefix + b
        run.font.name = "Calibri"
        run.font.size = Pt(size)
        run.font.bold = (i == 0 and bold_first)
        run.font.color.rgb = color
    return tb

# ── Helper: section label bar ────────────────────────────────────
def add_section_bar(slide, label, color=TEAL):
    add_rect(slide, 0, 0, 13.333, 0.55, color)
    add_text(slide, label, 0.3, 0.05, 12.5, 0.5, 22, bold=True,
             color=WHITE, align=PP_ALIGN.LEFT)

# ── Helper: slide background ─────────────────────────────────────
def set_bg(slide, color=LIGHT_BG):
    add_rect(slide, 0, 0, 13.333, 7.5, color)

# ── Helper: fetch + embed image ──────────────────────────────────
def embed_image(slide, url, x, y, w, h=None):
    try:
        result = json.loads(subprocess.check_output(
            ["python", "/tmp/skills/shared/scripts/fetch_images.py", url],
            timeout=30
        ))
        if result and result[0].get("base64"):
            raw_b64 = result[0]["base64"]
            if "," in raw_b64:
                raw_b64 = raw_b64.split(",", 1)[1]
            img_bytes = BytesIO(base64.b64decode(raw_b64))
            if h:
                slide.shapes.add_picture(img_bytes, Inches(x), Inches(y),
                                         Inches(w), Inches(h))
            else:
                slide.shapes.add_picture(img_bytes, Inches(x), Inches(y), Inches(w))
    except Exception as e:
        print(f"Image embed failed for {url}: {e}", file=sys.stderr)

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 1 – TITLE
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
# Full navy background
add_rect(s, 0, 0, 13.333, 7.5, NAVY)
# Teal accent bar top
add_rect(s, 0, 0, 13.333, 0.12, TEAL)
# Teal accent bar bottom
add_rect(s, 0, 7.38, 13.333, 0.12, TEAL)
# Orange vertical accent
add_rect(s, 0.5, 1.8, 0.08, 3.9, ORANGE)

add_text(s, "NON-HEMORRHAGIC STROKE", 0.8, 1.7, 12, 1.4, 44, bold=True,
         color=WHITE)
add_text(s, "Indications & Acute Management", 0.8, 3.1, 12, 0.8, 26,
         color=RGBColor(0xA8, 0xD8, 0xEA))
add_text(s, "Including Thrombolytic Therapy", 0.8, 3.85, 10, 0.6, 22,
         italic=True, color=RGBColor(0xFF, 0xA5, 0x00))
add_text(s, "General Medicine  |  Final Year MBBS", 0.8, 5.5, 12, 0.5, 17,
         color=MID_GRAY)
add_text(s, "AHA/ASA Guidelines 2019 | Davidson's | Harrison's | Rosen's EM",
         0.8, 6.2, 12, 0.4, 13, italic=True,
         color=RGBColor(0x78, 0x85, 0x92))

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 2 – DEFINITION & TYPES
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "Definition & Classification of Stroke")

# Left column – definition box
add_rect(s, 0.3, 0.7, 6.1, 1.8, NAVY)
add_text(s, "STROKE (CVA) – WHO Definition",
         0.5, 0.75, 5.8, 0.5, 14, bold=True, color=WHITE)
add_text(s, "Rapidly developing clinical signs of focal (or global) "
            "disturbance of cerebral function, lasting more than 24 hours "
            "or leading to death, with no apparent cause other than vascular.",
         0.5, 1.15, 5.8, 1.2, 13, color=RGBColor(0xD0, 0xE8, 0xF5), wrap=True)

# Types
add_rect(s, 0.3, 2.65, 6.1, 0.45, TEAL)
add_text(s, "TYPES OF STROKE", 0.5, 2.68, 5, 0.38, 14, bold=True, color=WHITE)

type_data = [
    ("Ischemic (Non-Hemorrhagic)  ~87%", ORANGE, True),
    ("  Thrombotic  |  Embolic  |  Lacunar", DARK_TEXT, False),
    ("Hemorrhagic  ~13%", DARK_TEXT, True),
    ("  Intracerebral (ICH)  |  Subarachnoid (SAH)", DARK_TEXT, False),
]
yy = 3.2
for txt, col, bold in type_data:
    add_text(s, txt, 0.6, yy, 5.8, 0.4, 14, bold=bold, color=col)
    yy += 0.38

# Right column – TOAST classification
add_rect(s, 6.8, 0.7, 6.2, 0.45, TEAL)
add_text(s, "TOAST Classification of Ischemic Stroke", 6.95, 0.73, 6, 0.38, 13, bold=True, color=WHITE)

toast = [
    "Large-artery atherosclerosis (thrombotic / embolic from plaque)",
    "Cardioembolism (AF, valvular disease, MI, dilated CMP)",
    "Small-vessel occlusion (lacunar – lenticulostriate arteries)",
    "Stroke of other determined etiology (vasculitis, dissection, hypercoag.)",
    "Stroke of undetermined etiology (cryptogenic)"
]
yy2 = 1.25
for i, t in enumerate(toast):
    add_rect(s, 6.8, yy2, 0.4, 0.38, TEAL if i % 2 == 0 else NAVY)
    add_text(s, str(i+1), 6.82, yy2+0.01, 0.35, 0.38, 13, bold=True, color=WHITE, align=PP_ALIGN.CENTER)
    add_text(s, t, 7.3, yy2, 5.6, 0.42, 12.5, color=DARK_TEXT)
    yy2 += 0.5

add_text(s, "Ischemic stroke constitutes ~87% of all strokes — FOCUS of this session",
         0.3, 6.75, 12.7, 0.4, 12, italic=True, color=TEAL)

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 3 – PATHOPHYSIOLOGY
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "Pathophysiology of Ischemic Stroke")

add_text(s, "The Ischemic Penumbra Concept", 0.3, 0.65, 9, 0.55, 20,
         bold=True, color=NAVY)

# Core vs Penumbra boxes
for i, (label, desc, col) in enumerate([
    ("ISCHEMIC CORE", "CBF < 10 mL/100g/min\nIrreversible neuronal death\nCytotoxic edema\nNo ATP production", RGBColor(0xC0, 0x39, 0x2B)),
    ("PENUMBRA", "CBF 10–20 mL/100g/min\nElectrically silent but viable\nSalvageable with reperfusion\n\"Time is Brain\"", ORANGE),
    ("OLIGEMIA", "CBF 20–55 mL/100g/min\nAutoreg. still intact\nAt-risk if CBF falls\nCollateral circulation", TEAL),
]):
    x = 0.3 + i * 4.3
    add_rect(s, x, 1.3, 4.0, 0.5, col)
    add_text(s, label, x+0.1, 1.32, 3.8, 0.45, 14, bold=True, color=WHITE)
    add_rect(s, x, 1.8, 4.0, 1.9, RGBColor(0xF8, 0xF9, 0xFA))
    for j, line in enumerate(desc.split("\n")):
        add_text(s, "• " + line, x+0.15, 1.85 + j*0.45, 3.8, 0.42, 13, color=DARK_TEXT)

# Cascade
add_rect(s, 0.3, 3.85, 12.7, 0.42, NAVY)
add_text(s, "Ischemic Cascade", 0.5, 3.88, 4, 0.35, 14, bold=True, color=WHITE)

cascade = [
    "↓ Cerebral blood flow",
    "→  ATP depletion",
    "→  Ion pump failure",
    "→  Glutamate excitotoxicity",
    "→  Ca²⁺ influx",
    "→  Free radicals",
    "→  Neuronal death"
]
x_pos = 0.3
for item in cascade:
    add_text(s, item, x_pos, 4.35, 1.75, 0.4, 11.5, color=DARK_TEXT)
    x_pos += 1.72

add_text(s, "Normal CBF = 55 mL/100g/min  |  Penumbra is the THERAPEUTIC TARGET of thrombolysis",
         0.3, 5.6, 12.7, 0.4, 13, italic=True, color=TEAL)

# Time chart
add_rect(s, 0.3, 6.1, 12.7, 0.9, RGBColor(0xE8, 0xF4, 0xFD))
add_text(s, "Time windows: 0–3 h (Class I tPA)  |  3–4.5 h (Class I with restrictions)  |  0–24 h (Thrombectomy in select cases)",
         0.5, 6.25, 12.3, 0.55, 14, bold=True, color=NAVY)

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 4 – CLINICAL FEATURES / INDICATIONS FOR TREATMENT
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "Clinical Features & Indications for Acute Intervention")

# Two-column layout
add_rect(s, 0.3, 0.65, 6.0, 0.45, NAVY)
add_text(s, "CLINICAL FEATURES BY TERRITORY", 0.45, 0.67, 5.6, 0.38, 13, bold=True, color=WHITE)

territories = [
    ("MCA territory (most common)", [
        "Contralateral hemiplegia / hemiparesis",
        "Hemisensory loss (face + arm > leg)",
        "Homonymous hemianopia",
        "Aphasia (dominant); Neglect (non-dominant)",
        "Eyes deviate toward lesion ('wrong way gaze')",
    ]),
    ("ACA territory", [
        "Contralateral leg > arm weakness",
        "Urinary incontinence",
        "Personality changes / abulia",
    ]),
    ("PCA territory", [
        "Contralateral homonymous hemianopia",
        "Visual agnosia, alexia without agraphia",
        "Thalamic syndrome (pain, sensory loss)",
    ]),
    ("Brainstem / Posterior circulation", [
        "5 D's: Diplopia, Dysphagia, Dysarthria,",
        "Dizziness, Drop attacks",
        "Crossed cranial nerve + limb signs",
        "Horner's syndrome (lateral medullary)",
    ]),
]

y = 1.18
for title, feats in territories:
    add_rect(s, 0.3, y, 6.0, 0.35, TEAL)
    add_text(s, title, 0.45, y+0.02, 5.7, 0.3, 12.5, bold=True, color=WHITE)
    y += 0.37
    for f in feats:
        add_text(s, "• " + f, 0.5, y, 5.8, 0.32, 11.5, color=DARK_TEXT)
        y += 0.3
    y += 0.08

# Right column – indications for thrombolysis
add_rect(s, 6.6, 0.65, 6.4, 0.45, ORANGE)
add_text(s, "INDICATIONS FOR THROMBOLYTIC THERAPY (IV tPA)", 6.75, 0.67, 6.1, 0.38, 12.5, bold=True, color=WHITE)

indications = [
    ("Time Criteria", [
        "Onset to treatment within 3 h (standard)",
        "3–4.5 h window (selected patients)",
        "Wake-up stroke: DWI+/FLAIR- on MRI",
    ]),
    ("Clinical Criteria", [
        "Ischemic stroke with measurable neurological deficit",
        "NIHSS > 0 with disabling symptoms",
        "Age ≥ 18 years (no upper age limit within 3 h)",
    ]),
    ("Laboratory Criteria", [
        "BP < 185/110 mm Hg (or can be safely lowered)",
        "Blood glucose > 50 mg/dL",
        "No intracranial hemorrhage on CT",
        "Platelet count ≥ 100,000; INR ≤ 1.7; aPTT ≤ 40 s",
    ]),
]

y2 = 1.18
for title, pts in indications:
    add_rect(s, 6.6, y2, 6.4, 0.35, NAVY)
    add_text(s, title, 6.75, y2+0.02, 6.1, 0.3, 12.5, bold=True, color=WHITE)
    y2 += 0.37
    for p in pts:
        add_text(s, "✓ " + p, 6.75, y2, 6.2, 0.32, 11.5, color=DARK_TEXT)
        y2 += 0.3
    y2 += 0.1

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 5 – NIHSS SCALE
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "NIH Stroke Scale (NIHSS) — Standardized Neurological Assessment")

add_text(s, "The NIHSS quantifies neurological deficit severity and guides thrombolysis decisions",
         0.3, 0.62, 12.7, 0.4, 14, italic=True, color=NAVY)

nihss_items = [
    ("1a", "Level of Consciousness", "0–3"),
    ("1b", "LOC Questions (month/age)", "0–2"),
    ("1c", "LOC Commands (eyes/fist)", "0–2"),
    ("2",  "Best Gaze", "0–2"),
    ("3",  "Visual Fields", "0–3"),
    ("4",  "Facial Palsy", "0–3"),
    ("5",  "Motor Arm (L+R)", "0–4 each"),
    ("6",  "Motor Leg (L+R)", "0–4 each"),
    ("7",  "Limb Ataxia", "0–2"),
    ("8",  "Sensory", "0–2"),
    ("9",  "Language/Aphasia", "0–3"),
    ("10", "Dysarthria", "0–2"),
    ("11", "Extinction/Neglect", "0–2"),
]

# Two columns
col1 = nihss_items[:7]
col2 = nihss_items[7:]

for col_items, x_start in [(col1, 0.3), (col2, 6.7)]:
    # Header
    add_rect(s, x_start, 1.1, 6.0, 0.38, NAVY)
    add_text(s, "Item", x_start+0.05, 1.12, 0.5, 0.32, 12, bold=True, color=WHITE)
    add_text(s, "Assessment", x_start+0.65, 1.12, 4.0, 0.32, 12, bold=True, color=WHITE)
    add_text(s, "Score", x_start+4.9, 1.12, 1.0, 0.32, 12, bold=True, color=WHITE)
    
    for i, (item, desc, score) in enumerate(col_items):
        bg = RGBColor(0xE8, 0xF4, 0xFD) if i % 2 == 0 else WHITE
        add_rect(s, x_start, 1.5 + i*0.42, 6.0, 0.4, bg)
        add_text(s, item, x_start+0.05, 1.52+i*0.42, 0.5, 0.36, 12, bold=True, color=TEAL)
        add_text(s, desc, x_start+0.65, 1.52+i*0.42, 4.1, 0.36, 12, color=DARK_TEXT)
        add_text(s, score, x_start+4.9, 1.52+i*0.42, 1.05, 0.36, 12, color=ORANGE, bold=True)

# Interpretation bar
add_rect(s, 0.3, 6.5, 12.7, 0.8, RGBColor(0x2C, 0x3E, 0x50))
interp = "0–4: Minor  |  5–15: Moderate  |  16–20: Moderate-Severe  |  21–42: Severe"
add_text(s, "NIHSS Interpretation:  " + interp, 0.5, 6.6, 12.3, 0.5, 13.5, bold=True, color=WHITE)

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 6 – IMMEDIATE INITIAL MANAGEMENT (ABCs)
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "Initial Emergency Management — ABCs & Stabilization")

add_text(s, '"Time is Brain" — 1.9 million neurons die every minute of untreated stroke',
         0.3, 0.62, 12.7, 0.4, 14, italic=True, bold=True, color=ORANGE)

steps = [
    ("A", "AIRWAY", NAVY, [
        "Assess for airway obstruction, noisy breathing",
        "Head tilt / jaw thrust if needed; consider intubation if GCS ≤ 8",
        "Supplemental O₂ to maintain SpO₂ > 94% (avoid hyperoxia)",
        "NPO until formal swallowing assessment by speech pathologist",
    ]),
    ("B", "BREATHING", TEAL, [
        "Pulse oximetry; ABG if SpO₂ borderline",
        "Ventilatory assistance if hypoventilating",
        "Avoid hypercapnia (worsens ICP) and hypocapnia",
        "Prevent aspiration — HOB ≥ 30°",
    ]),
    ("C", "CIRCULATION", RGBColor(0x17, 0x6A, 0x38), [
        "Cardiac monitoring minimum 48 h (detect AF/arrhythmias)",
        "12-lead ECG + serum troponin on arrival",
        "Large-bore IV access × 2; IV normal saline",
        "Avoid hypotension; target SBP 160–200 mmHg initially",
    ]),
    ("D", "DISABILITY / NEURO", ORANGE, [
        "GCS, NIHSS assessment",
        "Blood glucose — treat hypoglycemia (< 60 mg/dL) urgently",
        "Temperature — treat fever aggressively (paracetamol; cooling)",
        "Avoid hyperglycemia — target 140–180 mg/dL",
    ]),
]

for i, (letter, title, col, pts) in enumerate(steps):
    x = 0.3 + i * 3.25
    add_rect(s, x, 1.1, 3.0, 0.55, col)
    add_text(s, letter, x+0.08, 1.1, 0.5, 0.52, 26, bold=True, color=WHITE)
    add_text(s, title, x+0.55, 1.2, 2.35, 0.4, 14, bold=True, color=WHITE)
    yy = 1.75
    for p in pts:
        add_text(s, "• " + p, x+0.05, yy, 3.1, 0.38, 11.5, color=DARK_TEXT)
        yy += 0.38

# Bottom: labs
add_rect(s, 0.3, 5.7, 12.7, 1.6, RGBColor(0xE8, 0xF4, 0xFD))
add_text(s, "Immediate Labs & Investigations", 0.5, 5.75, 12, 0.35, 14, bold=True, color=NAVY)
labs = [
    "CBC with diff & platelets",
    "PT / INR / aPTT",
    "Blood glucose (stat)",
    "Electrolytes, BUN, Creatinine",
    "Liver function tests",
    "Cardiac troponin",
    "12-lead ECG",
    "Non-contrast CT head (NCCT) — STAT",
    "CXR",
    "Toxicology screen (if indicated)",
]
x_l = 0.5
y_l = 6.18
for i, lab in enumerate(labs):
    col_x = x_l + (i % 5) * 2.55
    row_y = y_l + (i // 5) * 0.38
    add_text(s, "• " + lab, col_x, row_y, 2.5, 0.36, 11.5, color=DARK_TEXT)

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 7 – BLOOD PRESSURE MANAGEMENT
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "Blood Pressure Management in Acute Ischemic Stroke")

add_text(s, "Cerebral autoregulation is IMPAIRED in ischemic stroke — perfusion is pressure-dependent",
         0.3, 0.62, 12.7, 0.4, 14, italic=True, color=NAVY)

scenarios = [
    ("NOT FOR tPA\n(No treatment)", TEAL, 
     ["Allow permissive hypertension",
      "Do NOT treat unless SBP > 220 mmHg",
      "  OR DBP > 120 mmHg",
      "Lower BP by ~15% in first 24 h only if",
      "  very severe (>220/>120)",
      "Exception: Aortic dissection, AMI,",
      "  severe heart failure, renal failure"]),
    ("ELIGIBLE FOR tPA\n(Pre-thrombolysis)", ORANGE,
     ["Must achieve BP < 185/110 mmHg",
      "  BEFORE starting alteplase",
      "Agents: Labetalol 10–20 mg IV bolus",
      "  OR Nicardipine infusion 5 mg/h",
      "  OR Hydralazine 10 mg IV",
      "Do NOT give tPA if BP cannot be",
      "  safely controlled to < 185/110"]),
    ("POST-tPA\nBP monitoring", NAVY,
     ["Target BP ≤ 180/105 mmHg",
      "Monitor Q15 min × 2h then Q30 min × 6h",
      "  then Q1h × 16h",
      "Treat SBP > 180 or DBP > 105",
      "Watch for hemorrhagic transformation",
      "Never lower BP abruptly",
      "Avoid hypotension at all times"]),
    ("Antihypertensive\nAgents Used", RGBColor(0x17, 0x6A, 0x38),
     ["Labetalol 10–20 mg IV over 1–2 min",
      "  (repeat q10 min; max 300 mg)",
      "Nicardipine 5–15 mg/h infusion",
      "Clevidipine 1–21 mg/h infusion",
      "Hydralazine 10–20 mg IV",
      "AVOID nitroprusside (ICP rise)",
      "AVOID sublingual nifedipine"]),
]

for i, (title, col, pts) in enumerate(scenarios):
    x = 0.3 + i * 3.25
    add_rect(s, x, 1.1, 3.0, 0.75, col)
    add_text(s, title, x+0.1, 1.12, 2.85, 0.7, 12.5, bold=True, color=WHITE)
    yy = 1.93
    for p in pts:
        add_text(s, p if p.startswith("  ") else "• " + p, x+0.05, yy, 3.1, 0.35, 11, color=DARK_TEXT)
        yy += 0.35

add_rect(s, 0.3, 6.8, 12.7, 0.45, RGBColor(0xFF, 0xF3, 0xCD))
add_text(s, "KEY PEARL: Avoid treating BP in acute stroke UNLESS pre-tPA criteria apply. Permissive hypertension maintains penumbral perfusion.",
         0.5, 6.83, 12.3, 0.38, 12.5, bold=True, color=RGBColor(0x7D, 0x41, 0x00))

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 8 – IV tPA: MECHANISM & DOSING
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "Intravenous Alteplase (IV tPA) — Mechanism & Dosing Protocol")

# Mechanism box
add_rect(s, 0.3, 0.65, 5.8, 4.5, RGBColor(0xE8, 0xF4, 0xFD))
add_rect(s, 0.3, 0.65, 5.8, 0.45, NAVY)
add_text(s, "MECHANISM OF ACTION", 0.45, 0.67, 5.5, 0.38, 14, bold=True, color=WHITE)

mech = [
    "Alteplase = recombinant tissue plasminogen activator (rtPA)",
    "Binds to fibrin in thrombus with high specificity",
    "Converts plasminogen → plasmin",
    "Plasmin cleaves fibrin → clot dissolution",
    "Restores blood flow to ischemic penumbra",
    "Half-life: ~4–5 minutes",
    "Cleared by liver",
    "Fibrin-specific (less systemic lysis than streptokinase)",
]
for i, m in enumerate(mech):
    add_text(s, ("→  " if i > 0 else "•  ") + m, 0.45, 1.18 + i*0.44, 5.7, 0.42, 12.5, color=DARK_TEXT)

# Dosing protocol
add_rect(s, 6.4, 0.65, 6.6, 4.5, RGBColor(0xFFF8F0))
add_rect(s, 6.4, 0.65, 6.6, 0.45, ORANGE)
add_text(s, "ALTEPLASE DOSING PROTOCOL", 6.55, 0.67, 6.3, 0.38, 14, bold=True, color=WHITE)

dose_info = [
    ("Standard Dose", "0.9 mg/kg IV\n(maximum 90 mg)"),
    ("Loading Bolus", "10% of total dose given over 1 minute"),
    ("Infusion", "Remaining 90% over 60 minutes"),
    ("Example (70 kg)", "Total = 63 mg\nBolus = 6.3 mg IV push\nInfusion = 56.7 mg over 60 min"),
    ("Route", "IV only — do NOT give IM or intra-arterially as primary route"),
    ("Monitoring", "Neurological checks Q15 min during infusion\nBP monitoring as per protocol above"),
]

yy = 1.18
for label, val in dose_info:
    add_rect(s, 6.4, yy, 2.2, 0.8, TEAL)
    add_text(s, label, 6.5, yy+0.1, 2.0, 0.6, 11.5, bold=True, color=WHITE)
    add_text(s, val, 8.7, yy+0.05, 4.2, 0.75, 12, color=DARK_TEXT)
    yy += 0.85

# Post tPA actions
add_rect(s, 0.3, 5.3, 12.7, 0.45, NAVY)
add_text(s, "AFTER ALTEPLASE: Admit to Stroke Unit / ICU  |  No antiplatelets/anticoagulants for 24 h  |  MRI/CT head at 24 h  |  Watch for angioedema",
         0.5, 5.33, 12.3, 0.38, 12.5, bold=True, color=WHITE)

add_rect(s, 0.3, 5.82, 12.7, 1.5, RGBColor(0xFDE8E8))
add_text(s, "COMPLICATIONS OF IV tPA", 0.5, 5.88, 6, 0.38, 13, bold=True, color=RGBColor(0x8B, 0x00, 0x00))
complications = [
    "Symptomatic intracranial hemorrhage (sICH): ~6%",
    "Orolingual angioedema: 1–5%",
    "Systemic bleeding",
    "Reperfusion injury",
    "Early neurological deterioration",
]
x_c = 0.5
for i, c in enumerate(complications):
    cx = x_c + (i % 3) * 4.2
    cy = 6.3 + (i // 3) * 0.38
    add_text(s, "⚠ " + c, cx, cy, 4.1, 0.35, 11.5, color=RGBColor(0x8B, 0x00, 0x00))

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 9 – CONTRAINDICATIONS TO tPA
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "Contraindications to IV Alteplase (AHA/ASA 2019)")

# Absolute column
add_rect(s, 0.3, 0.65, 5.9, 0.45, RGBColor(0xC0, 0x39, 0x2B))
add_text(s, "ABSOLUTE CONTRAINDICATIONS", 0.45, 0.67, 5.6, 0.38, 14, bold=True, color=WHITE)

abs_ci = [
    "Evidence of intracranial hemorrhage on CT",
    "Significant head trauma or stroke in last 3 months",
    "Previous intracranial surgery in past 3 months",
    "History of intracranial hemorrhage",
    "Intracranial neoplasm, AVM, or aneurysm",
    "Active internal bleeding (excluding menstruation)",
    "Suspected aortic arch dissection",
    "Infective endocarditis",
    "SBP > 185 or DBP > 110 (uncontrolled)",
    "Platelet count < 100,000 / mm³",
    "INR > 1.7 (if on warfarin)",
    "aPTT > 40 s (if on heparin)",
    "Blood glucose < 50 mg/dL",
    "Direct thrombin inhibitors / Xa inhibitors in last 48 h",
    "Full treatment dose LMWH in last 24 h",
]
yy = 1.18
for ci in abs_ci:
    add_text(s, "✗  " + ci, 0.45, yy, 5.7, 0.33, 11.5, color=RGBColor(0x7B, 0x00, 0x00))
    yy += 0.33

# Relative column  
add_rect(s, 6.5, 0.65, 6.5, 0.45, ORANGE)
add_text(s, "RELATIVE CONTRAINDICATIONS (3–4.5 h window)", 6.65, 0.67, 6.2, 0.38, 13, bold=True, color=WHITE)

rel_ci = [
    "Age > 80 years",
    "NIHSS score > 25 (severe stroke)",
    "History of both DM AND prior stroke",
    "Imaging showing > 1/3 MCA territory involvement",
    "Taking oral anticoagulants",
]
yy2 = 1.18
for rc in rel_ci:
    add_text(s, "⚠  " + rc, 6.65, yy2, 6.2, 0.36, 12.5, color=RGBColor(0x7D, 0x41, 0x00))
    yy2 += 0.38

# Note about 3h window
add_rect(s, 6.5, yy2+0.1, 6.5, 0.45, TEAL)
add_text(s, "NOTE: No upper age limit for 0–3 h window", 6.65, yy2+0.12, 6.2, 0.38, 13, bold=True, color=WHITE)
yy2 += 0.65

add_rect(s, 6.5, yy2, 6.5, 0.45, NAVY)
add_text(s, "Mild nondisabling stroke (NIHSS 0–5, non-disabling)", 6.65, yy2+0.02, 6.2, 0.38, 12.5, bold=True, color=RGBColor(0xFF, 0xA0, 0x00))
add_text(s, "IV alteplase NOT recommended (PRISMS trial)", 6.65, yy2+0.2, 6.2, 0.38, 12, color=WHITE)

add_rect(s, 0.3, 6.75, 12.7, 0.55, RGBColor(0xFFF3CD))
add_text(s, "RULE OF THUMB: When in doubt — obtain CT head STAT, check BP, glucose, coags. If any absolute CI present → do NOT give tPA.",
         0.5, 6.78, 12.3, 0.46, 12.5, bold=True, color=RGBColor(0x7D, 0x41, 0x00))

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 10 – CT IMAGE + Penumbra imaging slide
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "Neuroimaging in Acute Ischemic Stroke")

add_text(s, "NCCT Head — First-line imaging: Rules out hemorrhage. MRI-DWI — Gold standard for early infarct detection.",
         0.3, 0.62, 12.7, 0.4, 13, italic=True, color=NAVY)

# Image 1 – CT comparison
embed_image(s, "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_8c984050a4657747f99e63b46b61788a1bc2089bec72be63731970ba6e8e585c.jpg",
            0.3, 1.1, 5.8, 3.4)
add_text(s, "CT: Baseline vs. 48h — Left basal ganglia infarct (AChA territory)",
         0.3, 4.6, 5.8, 0.45, 11, italic=True, color=MID_GRAY)

# Image 2 – CT perfusion
embed_image(s, "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_9ddb9786c87b8ef665592c1ff5a780f0fd16028d71ae2a8cabfdf23d702b683e.jpg",
            6.4, 1.1, 6.6, 3.4)
add_text(s, "CT Perfusion (CTP-RAPID): Pink = infarct core | Green = salvageable penumbra",
         6.4, 4.6, 6.6, 0.45, 11, italic=True, color=MID_GRAY)

# Key imaging points
add_rect(s, 0.3, 5.15, 12.7, 0.42, NAVY)
add_text(s, "Imaging Algorithm", 0.5, 5.17, 3, 0.36, 13, bold=True, color=WHITE)
add_text(s, "1. NCCT head (STAT) → Rule out hemorrhage / major infarct  2. CTA (if thrombectomy candidate)  3. CTP or MRI-DWI if extended window",
         3.5, 5.17, 9.5, 0.36, 12.5, color=WHITE)

img_notes = [
    ("NCCT", "Normal in first 6 h\nHyperdense MCA sign\nEarly ischemic changes: loss of insular ribbon, sulcal effacement"),
    ("DWI-MRI", "Positive within 30 min of onset\nRestricted diffusion = bright signal\nMost sensitive for acute infarct"),
    ("FLAIR-MRI", "Negative in first 6 h post-onset\nDWI+/FLAIR- = <4.5 h onset\n(WAKE-UP trial basis)"),
    ("CTA/MRA", "Detects vessel occlusion\nGuides thrombectomy decision\nAssesses collateral circulation"),
]
for i, (modality, desc) in enumerate(img_notes):
    x_i = 0.3 + i * 3.25
    add_rect(s, x_i, 5.65, 3.05, 0.45, TEAL if i % 2 == 0 else ORANGE)
    add_text(s, modality, x_i+0.1, 5.67, 2.85, 0.38, 13, bold=True, color=WHITE)
    for j, line in enumerate(desc.split("\n")):
        add_text(s, "• " + line, x_i+0.1, 6.15 + j*0.38, 2.95, 0.36, 11, color=DARK_TEXT)

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 11 – MECHANICAL THROMBECTOMY
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "Mechanical Thrombectomy (Endovascular Therapy)")

add_text(s, "Large vessel occlusion (LVO) of ICA / M1-M2 MCA / basilar artery — thrombectomy is CLASS I recommendation",
         0.3, 0.62, 12.7, 0.4, 14, italic=True, bold=True, color=NAVY)

# Indications box
add_rect(s, 0.3, 1.1, 5.8, 0.42, TEAL)
add_text(s, "INDICATIONS FOR THROMBECTOMY", 0.45, 1.12, 5.6, 0.35, 13, bold=True, color=WHITE)

thromb_ind = [
    "Pre-treatment NIHSS ≥ 6",
    "Age ≥ 18 years",
    "LVO on CTA/MRA: ICA, M1/M2 MCA, basilar artery",
    "Alberta Stroke Program Early CT Score (ASPECTS) ≥ 6",
    "Within 6 h of symptom onset (standard)",
    "6–16 h with favorable imaging (DAWN/DEFUSE-3 trial criteria)",
    "Up to 24 h in selected patients (DAWN trial — wake-up stroke)",
    "Premorbid mRS 0–1 (independent prior to stroke)",
    "Can be done WITH or WITHOUT prior IV tPA",
]
yy = 1.6
for ind in thromb_ind:
    add_text(s, "✓  " + ind, 0.45, yy, 5.7, 0.36, 12, color=DARK_TEXT)
    yy += 0.36

# Procedure details
add_rect(s, 6.4, 1.1, 6.6, 0.42, ORANGE)
add_text(s, "PROCEDURE & KEY POINTS", 6.55, 1.12, 6.3, 0.35, 13, bold=True, color=WHITE)

proc = [
    ("Device", "Stent retriever (Solitaire, Trevo) — first-line\nDirect aspiration (ADAPT technique) — alternative"),
    ("Access", "Femoral artery → guide catheter → microcatheter\nDeployed past thrombus → stent retrieves clot"),
    ("Goal", "Recanalization (TICI 2b/3 = successful reperfusion)\nDoor-to-groin < 90 min ideal"),
    ("Anesthesia", "Conscious sedation preferred over GA\n(GA associated with worse outcomes in trials)"),
    ("Benefit", "NNT = 2.6 (number needed to treat for 1 good outcome)\nSignificant reduction in disability at 90 days"),
    ("Trials", "MR CLEAN, ESCAPE, SWIFT PRIME, EXTEND-IA,\nTHAWS, DAWN, DEFUSE-3 — all positive"),
]

yy = 1.6
for label, val in proc:
    add_rect(s, 6.4, yy, 1.5, 0.65, NAVY)
    add_text(s, label, 6.5, yy+0.08, 1.35, 0.5, 12, bold=True, color=WHITE, align=PP_ALIGN.CENTER)
    add_text(s, val, 7.98, yy+0.04, 4.95, 0.62, 11.5, color=DARK_TEXT)
    yy += 0.7

add_rect(s, 0.3, 6.78, 12.7, 0.5, RGBColor(0xE8, 0xF8, 0xEE))
add_text(s, "Bridge therapy: Give IV tPA first (if eligible) then proceed to thrombectomy — combined approach is standard of care",
         0.5, 6.82, 12.3, 0.4, 13, bold=True, color=RGBColor(0x0B, 0x5E, 0x2C))

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 12 – ANTIPLATELET & ANTICOAGULATION THERAPY
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "Antiplatelet & Anticoagulation Therapy in Acute Ischemic Stroke")

add_rect(s, 0.3, 0.65, 5.8, 0.45, TEAL)
add_text(s, "ANTIPLATELET THERAPY", 0.45, 0.67, 5.6, 0.38, 14, bold=True, color=WHITE)

anti_plt = [
    "Aspirin 300 mg loading dose STAT (if no tPA given)",
    "Start aspirin within 24–48 h of stroke onset",
    "If tPA given: wait 24 h before starting aspirin",
    "Dual antiplatelet (Aspirin + Clopidogrel):",
    "  → For minor stroke (NIHSS ≤ 3) or high-risk TIA",
    "  → CHANCE trial: 21-day dual therapy ↓ recurrence",
    "  → POINT trial: confirms CHANCE findings (90 days)",
    "Long-term secondary prevention: aspirin 75–100 mg/day",
    "  OR clopidogrel 75 mg/day (if aspirin intolerant)",
    "  OR aspirin + dipyridamole MR 200 mg BD",
]
yy = 1.18
for a in anti_plt:
    add_text(s, a if a.startswith("  ") else "• " + a, 0.45, yy, 5.7, 0.36, 12, color=DARK_TEXT)
    yy += 0.36

add_rect(s, 6.4, 0.65, 6.6, 0.45, NAVY)
add_text(s, "ANTICOAGULATION THERAPY", 6.55, 0.67, 6.3, 0.38, 14, bold=True, color=WHITE)

anticaog = [
    "NOT routinely used for acute ischemic stroke",
    "Cardioembolic stroke (AF): START anticoagulation",
    "  but timing debate — '1-3-6-12 rule':",
    "  → TIA: start immediately",
    "  → Minor stroke (NIHSS ≤ 8): day 3",
    "  → Moderate stroke (NIHSS 8–16): day 6",
    "  → Severe stroke (NIHSS > 16): day 12",
    "Warfarin: INR target 2–3 for non-valvular AF",
    "DOACs: Rivaroxaban, Apixaban, Dabigatran preferred",
    "  for non-valvular AF (RELY, ROCKET-AF, ARISTOTLE)",
    "Heparin: NOT recommended routinely (CAST, IST trials)",
    "VTE prophylaxis: LMWH + compression stockings",
]
yy2 = 1.18
for a in anticaog:
    add_text(s, a if a.startswith("  ") else "• " + a, 6.55, yy2, 6.3, 0.36, 12, color=DARK_TEXT)
    yy2 += 0.36

add_rect(s, 0.3, 6.7, 12.7, 0.55, RGBColor(0xFFF3CD))
add_text(s, "KEY EXAM POINT: Aspirin within 24–48 h is standard. IV heparin is NOT indicated routinely in acute ischemic stroke.",
         0.5, 6.73, 12.3, 0.46, 13, bold=True, color=RGBColor(0x7D, 0x41, 0x00))

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 13 – SUPPORTIVE CARE & COMPLICATIONS
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "Supportive Care, Prevention of Complications & Cerebral Edema")

items = [
    ("Fever", TEAL, [
        "Hyperthermia worsens ischemic injury",
        "Target temperature < 37.5°C",
        "Paracetamol 1g QID for fever",
        "Cooling blankets if refractory",
        "Treat infections aggressively",
    ]),
    ("Glucose", ORANGE, [
        "Hyperglycemia worsens infarct",
        "Target 140–180 mg/dL",
        "Insulin infusion if glucose > 180",
        "Avoid hypoglycemia (< 60 mg/dL)",
        "SHINE trial: intensive control = no benefit",
    ]),
    ("Cerebral Edema", NAVY, [
        "Peak at 72–120 h post-stroke",
        "Malignant MCA infarct = risk of herniation",
        "HOB 20–30°; avoid hypotonic fluids",
        "Osmotherapy: Mannitol 1 g/kg IV",
        "Hypertonic saline (3% NaCl) — evidence growing",
        "Decompressive craniectomy (DESTINY-2 trial)",
        "NO role for corticosteroids in ischemic stroke",
    ]),
    ("DVT / PE\nProphylaxis", RGBColor(0x17, 0x6A, 0x38), [
        "Immobile patients at high VTE risk",
        "Graduated compression stockings",
        "Pneumatic compression devices",
        "LMWH after 24 h (if no hemorrhagic transformation)",
        "Early mobilization when safe",
    ]),
    ("Nutrition\n& Swallowing", RGBColor(0x6C, 0x35, 0x83), [
        "Dysphagia in ~50% of stroke patients",
        "NPO until swallowing assessed",
        "Formal swallowing screen by speech pathologist",
        "NG tube / nasogastric feeding if unsafe swallow",
        "PEG for prolonged dysphagia (> 2–3 weeks)",
    ]),
    ("Neuroprotection\n& Statins", RGBColor(0x1A, 0x65, 0x5E), [
        "No proven neuroprotective agent to date",
        "Statins: High-intensity (Atorvastatin 80 mg)",
        "  ↓ recurrence by 16% (SPARCL trial)",
        "Start statins before discharge",
        "Continue pre-existing statins",
    ]),
]

for i, (title, col, pts) in enumerate(items):
    row, ci = divmod(i, 3)
    x = 0.3 + ci * 4.3
    y = 0.75 + row * 3.3
    add_rect(s, x, y, 4.0, 0.48, col)
    add_text(s, title, x+0.1, y+0.04, 3.8, 0.42, 13, bold=True, color=WHITE)
    yy = y + 0.55
    for p in pts:
        add_text(s, p if p.startswith("  ") else "• " + p, x+0.1, yy, 3.85, 0.35, 11.5, color=DARK_TEXT)
        yy += 0.35

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 14 – STROKE UNIT & CHAIN OF SURVIVAL
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
set_bg(s)
add_section_bar(s, "Stroke Unit Care & The Acute Stroke Chain of Survival")

add_text(s, "Stroke unit care reduces mortality by 18%, disability, and nursing home placement — STRONGER than any single drug",
         0.3, 0.62, 12.7, 0.42, 14, italic=True, color=NAVY)

chain = [
    ("RECOGNITION", "Sudden face drooping\nArm weakness\nSpeech difficulty\nCall emergency services\n(FAST acronym)", TEAL),
    ("DISPATCH &\nTRANSPORT", "Pre-notification to\nstroke center\nPatient positioning\nVital signs en route\nAvoid delays", ORANGE),
    ("ED TRIAGE\n(Door-to-CT < 25 min)", "Stroke team activation\nRapid NIHSS\nImmediate NCCT head\nLabs drawn\nIV access", NAVY),
    ("DIAGNOSIS\n(Door-to-DX < 45 min)", "CT reviewed for ICH\nEligibility for tPA\nassessed\nNeurology consult\nConsent", RGBColor(0x17, 0x6A, 0x38)),
    ("tPA / THROMBECT.\n(Door-to-needle < 60 min)", "Alteplase 0.9 mg/kg\nor IR team activated\nfor thrombectomy\nICU/Stroke unit\nadmission", RGBColor(0x6C, 0x35, 0x83)),
]

for i, (title, desc, col) in enumerate(chain):
    x = 0.2 + i * 2.6
    add_rect(s, x, 1.1, 2.4, 0.55, col)
    add_text(s, title, x+0.05, 1.12, 2.3, 0.48, 11.5, bold=True, color=WHITE, align=PP_ALIGN.CENTER)
    add_rect(s, x, 1.65, 2.4, 2.55, RGBColor(0xF0, 0xF6, 0xFA))
    for j, line in enumerate(desc.split("\n")):
        add_text(s, "• " + line, x+0.08, 1.72 + j*0.42, 2.3, 0.4, 11.5, color=DARK_TEXT)
    if i < 4:
        add_text(s, "→", x+2.4, 1.82, 0.18, 0.4, 22, bold=True, color=ORANGE)

# Key time targets
add_rect(s, 0.3, 4.4, 12.7, 0.42, NAVY)
add_text(s, "TIME TARGETS:  Door-to-CT < 25 min  |  Door-to-thrombolysis < 60 min  |  Door-to-groin (thrombectomy) < 90 min",
         0.5, 4.43, 12.3, 0.35, 13, bold=True, color=WHITE)

# Stroke unit benefits
add_rect(s, 0.3, 4.95, 12.7, 0.42, TEAL)
add_text(s, "What stroke units provide:", 0.5, 4.97, 3.5, 0.35, 13, bold=True, color=WHITE)

su_benefits = [
    "Continuous cardiac monitoring",
    "Regular neuro assessment",
    "BP/glucose management",
    "Early physiotherapy",
    "Speech therapy",
    "OT assessment",
    "DVT prevention",
    "Family education",
]
x_su = 4.0
for i, b in enumerate(su_benefits):
    cx = x_su + (i % 4) * 2.3
    cy = 4.97 + (i // 4) * 0.38
    add_text(s, "✓ " + b, cx, cy, 2.25, 0.36, 12, color=WHITE)

# Secondary prevention
add_rect(s, 0.3, 5.75, 12.7, 1.55, RGBColor(0xE8, 0xF8, 0xEE))
add_text(s, "SECONDARY PREVENTION (Post-Discharge):", 0.5, 5.82, 6, 0.35, 13, bold=True, color=RGBColor(0x0B, 0x5E, 0x2C))
sec_prev = [
    "Antiplatelet therapy (aspirin / clopidogrel)",
    "Statin therapy (atorvastatin 80 mg)",
    "Aggressive BP control (target < 130/80)",
    "Glycaemic control in diabetics",
    "Anticoagulation if cardioembolic (AF)",
    "Carotid endarterectomy / stenting if significant carotid stenosis",
    "Lifestyle: smoking cessation, weight loss, exercise, diet",
    "Cardiac investigation: Echo, Holter monitor for AF",
]
x_sp = 0.5
for i, sp in enumerate(sec_prev):
    cx = x_sp + (i % 4) * 3.2
    cy = 6.25 + (i // 4) * 0.38
    add_text(s, "• " + sp, cx, cy, 3.15, 0.36, 11.5, color=DARK_TEXT)

# ═══════════════════════════════════════════════════════════════════
#  SLIDE 15 – SUMMARY & KEY EXAM POINTS
# ═══════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, NAVY)
add_rect(s, 0, 0, 13.333, 0.12, TEAL)
add_rect(s, 0, 7.38, 13.333, 0.12, ORANGE)

add_text(s, "SUMMARY & HIGH-YIELD EXAM POINTS", 0.4, 0.18, 12.5, 0.65, 26,
         bold=True, color=WHITE, align=PP_ALIGN.CENTER)
add_rect(s, 0.3, 0.88, 12.7, 0.05, ORANGE)

key_points = [
    ("tPA Dose", "0.9 mg/kg IV (max 90 mg); 10% bolus + 90% over 60 min", ORANGE),
    ("tPA Window", "Class I: 0–3 h | Class I with restrictions: 3–4.5 h | Extended: DWI+/FLAIR- on MRI", TEAL),
    ("tPA BP threshold", "Must be < 185/110 mmHg before starting; maintain < 180/105 after", RGBColor(0xA8, 0xD8, 0xEA)),
    ("BP in stroke (no tPA)", "Permissive hypertension — treat only if > 220/120 mmHg", ORANGE),
    ("Aspirin", "300 mg loading if no tPA; 75–100 mg/day maintenance; dual APT for minor stroke/TIA", TEAL),
    ("Anticoagulation", "NOT routine; use for cardioembolic (AF) with 1-3-6-12 timing rule", RGBColor(0xA8, 0xD8, 0xEA)),
    ("Heparin", "NOT recommended routinely (CAST & IST trials — no benefit, increased hemorrhage)", ORANGE),
    ("Thrombectomy", "LVO + NIHSS ≥ 6 + ASPECTS ≥ 6 → up to 24 h (DAWN trial); door-to-groin < 90 min", TEAL),
    ("Steroids", "NO role in ischemic stroke (worsen hyperglycemia, increase infection risk)", RGBColor(0xA8, 0xD8, 0xEA)),
    ("Statins", "High-dose atorvastatin 80 mg — start before discharge (SPARCL trial)", ORANGE),
    ("Cerebral edema Rx", "Mannitol / hypertonic saline / decompressive craniectomy; NO steroids", TEAL),
    ("NIHSS > 15", "Indicates large infarction; consider thrombectomy workup", RGBColor(0xA8, 0xD8, 0xEA)),
]

x_kp = 0.3
y_kp = 1.05
for i, (label, fact, col) in enumerate(key_points):
    row, ci_idx = divmod(i, 2)
    x_box = x_kp + ci_idx * 6.4
    y_box = y_kp + row * 0.5
    add_rect(s, x_box, y_box, 1.6, 0.44, col)
    add_text(s, label, x_box+0.05, y_box+0.02, 1.55, 0.4, 11, bold=True, color=NAVY, align=PP_ALIGN.CENTER)
    add_text(s, fact, x_box+1.65, y_box+0.02, 4.6, 0.4, 11.5, color=WHITE)

add_rect(s, 0.3, 7.12, 12.7, 0.26, TEAL)
add_text(s, "References: AHA/ASA Stroke Guidelines 2019 | Rosen's Emergency Medicine 9e | Bradley & Daroff's Neurology | Textbook of Family Medicine 9e | Davidson's Principles & Practice of Medicine",
         0.5, 7.14, 12.3, 0.22, 9, italic=True, color=WHITE)

# ─── Save ─────────────────────────────────────────────────────────
out = "/tmp/workspace/stroke-ppt/Non_Hemorrhagic_Stroke_MBBS.pptx"
buf = BytesIO()
prs.save(buf)
with open(out, "wb") as f:
    f.write(buf.getvalue())
print(f"Saved: {out}")
print(f"Slides: {len(prs.slides)}")

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/stroke-ppt/build_stroke_ppt.py'

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/stroke-ppt/build_stroke_ppt.py'