Acute ischemic stroke

Typical presentation

• Balance: sudden dizziness, loss of coordination
• Eyes: sudden visual loss or diplopia
• Face: facial droop
• Arm: unilateral weakness or numbness
• Speech: dysarthria, aphasia, confusion
• Time: record the last known well time

Immediate assessment

1. Establish last-known-well time and perform focused neurologic assessment, often using NIHSS.
2. Check glucose immediately, because hypoglycemia can mimic stroke.
3. Stabilize airway, oxygenation, circulation, temperature, and cardiac rhythm.
4. Keep the patient nil by mouth until swallowing is assessed because aspiration is common after stroke.
5. Obtain urgent noncontrast CT head to exclude intracranial hemorrhage. CT angiography is commonly added to identify large-vessel occlusion and guide thrombectomy.
6. Obtain key labs, ECG, and cardiac monitoring, but do not unnecessarily delay reperfusion treatment.

Reperfusion treatment

• IV thrombolysis: Eligible patients with a disabling ischemic deficit may receive an IV clot-dissolving drug as quickly as possible, usually within 4.5 hours from onset or last known well. Eligibility depends on imaging, blood pressure, anticoagulant exposure, bleeding risk, platelet count, glucose, and other contraindications.
• Mechanical thrombectomy: For selected patients with a large-vessel occlusion, catheter-based clot retrieval is strongly indicated. It is time-sensitive and may benefit carefully selected patients up to 24 hours after last known well, using vascular and brain-tissue imaging.
• If a patient qualifies for both IV thrombolysis and thrombectomy, IV treatment should generally not be delayed while arranging endovascular therapy.

Early inpatient care

• Avoid hypoxia, fever, hypotension, hypoglycemia, and hyperglycemia.
• Treat blood pressure according to whether reperfusion therapy is planned, using the stroke team’s protocol.
• Start antithrombotic therapy only after hemorrhage is excluded and after the appropriate delay following thrombolysis.
• Identify the mechanism: atrial fibrillation/cardioembolism, carotid or intracranial atherosclerosis, small-vessel disease, dissection, or other causes.
• Begin secondary prevention: antiplatelet or anticoagulation when indicated, statin therapy, risk-factor control, smoking cessation, and rehabilitation.