const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = 'LAYOUT_WIDE';
pres.author = 'Medical Education';
pres.title = 'Approach and Management of Acute Ischemic Stroke';

// ─── Color Palette ─────────────────────────────────────────────────────────────
const C = {
  navy:     '0D2B55',   // deep navy – dominant bg
  teal:     '1A7A8A',   // teal accent
  cyan:     '00B4C8',   // highlight / accent
  white:    'FFFFFF',
  offWhite: 'E8F4F8',
  lightGray:'D0E8F0',
  yellow:   'FFD166',
  orange:   'F4845F',
  green:    '2EC4B6',
  red:      'E63946',
  darkText: '0D2B55',
  mutedText:'7BAEC4',
};

// ─── Master background helper ──────────────────────────────────────────────────
function navyBg(slide) {
  slide.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:13.3, h:7.5, fill:{color:C.navy}, line:{color:C.navy} });
}
function accentBar(slide, color=C.teal, y=0, h=0.07) {
  slide.addShape(pres.shapes.RECTANGLE, { x:0, y, w:13.3, h, fill:{color}, line:{color} });
}
function sectionTag(slide, label, x=0.35, y=0.15) {
  slide.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w:2.2, h:0.35, fill:{color:C.teal}, line:{color:C.teal}, rectRadius:0.06 });
  slide.addText(label, { x, y, w:2.2, h:0.35, fontSize:10, bold:true, color:C.white, align:'center', valign:'middle', margin:0 });
}
function slideTitle(slide, text, y=0.55, color=C.white) {
  slide.addText(text, { x:0.4, y, w:12.5, h:0.65, fontSize:26, bold:true, color, fontFace:'Calibri', charSpacing:0.5 });
}
function dividerLine(slide, y=1.25, color=C.teal) {
  slide.addShape(pres.shapes.RECTANGLE, { x:0.4, y, w:12.5, h:0.04, fill:{color}, line:{color} });
}
function footnote(slide, text) {
  slide.addText(text, { x:0.4, y:7.1, w:12.5, h:0.28, fontSize:8.5, color:C.mutedText, italic:true, align:'left' });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 – TITLE SLIDE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  // decorative left bar
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:0.22, h:7.5, fill:{color:C.teal}, line:{color:C.teal} });
  // decorative bottom bar
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:6.9, w:13.3, h:0.6, fill:{color:C.teal}, line:{color:C.teal} });
  // brain icon circle
  s.addShape(pres.shapes.ELLIPSE, { x:9.8, y:0.4, w:3.0, h:3.0, fill:{color:C.teal, transparency:75}, line:{color:C.cyan, w:2} });
  s.addShape(pres.shapes.ELLIPSE, { x:10.1, y:0.7, w:2.4, h:2.4, fill:{color:C.teal, transparency:60}, line:{color:C.teal} });
  s.addText('🧠', { x:10.2, y:0.85, w:2.2, h:2.0, fontSize:70, align:'center', valign:'middle' });

  s.addText('APPROACH AND MANAGEMENT OF', { x:0.5, y:1.4, w:9.0, h:0.55, fontSize:16, bold:false, color:C.cyan, charSpacing:3, fontFace:'Calibri' });
  s.addText('ACUTE ISCHEMIC\nSTROKE', { x:0.5, y:1.9, w:9.2, h:1.8, fontSize:46, bold:true, color:C.white, fontFace:'Calibri', lineSpacingMultiple:1.1 });
  s.addShape(pres.shapes.RECTANGLE, { x:0.5, y:3.75, w:3.8, h:0.06, fill:{color:C.yellow}, line:{color:C.yellow} });
  s.addText('Based on: Harrison\'s Principles of Internal Medicine (22nd ed., 2025)\nCurrent Medical Diagnosis & Treatment (CMDT)\nAPI Textbook of Medicine', { x:0.5, y:3.9, w:9.0, h:1.0, fontSize:12, color:C.offWhite, lineSpacingMultiple:1.5 });
  s.addText('"Time is Brain — 1.9 million neurons lost per minute of stroke"', { x:0.5, y:5.2, w:9.5, h:0.5, fontSize:13, italic:true, color:C.yellow, fontFace:'Calibri' });
  s.addText('Medical Education | May 2026', { x:0.5, y:7.1, w:6, h:0.28, fontSize:10, color:C.white });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 – OUTLINE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  accentBar(s, C.teal, 0, 0.07);
  sectionTag(s, 'OVERVIEW');
  slideTitle(s, 'Contents at a Glance');
  dividerLine(s);

  const items = [
    ['01', 'Epidemiology & Burden of Disease'],
    ['02', 'Definition & Classification (TOAST)'],
    ['03', 'Pathophysiology & Ischemic Penumbra'],
    ['04', 'Etiology & Risk Factors'],
    ['05', 'Clinical Presentation & Stroke Syndromes'],
    ['06', 'Diagnostic Approach & Imaging'],
    ['07', 'Acute Management — Thrombolysis (IV tPA)'],
    ['08', 'Acute Management — Mechanical Thrombectomy'],
    ['09', 'General & Supportive Care'],
    ['10', 'Secondary Prevention'],
    ['11', 'Rehabilitation & Stroke Units'],
    ['12', 'Key Takeaways'],
  ];

  const cols = 2;
  const perCol = 6;
  for (let i = 0; i < items.length; i++) {
    const col = Math.floor(i / perCol);
    const row = i % perCol;
    const x = 0.5 + col * 6.4;
    const y = 1.45 + row * 0.87;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w:5.9, h:0.72, fill:{color:'122E50'}, line:{color:C.teal, w:1}, rectRadius:0.08 });
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w:0.55, h:0.72, fill:{color:C.teal}, line:{color:C.teal}, rectRadius:0.08 });
    s.addText(items[i][0], { x, y, w:0.55, h:0.72, fontSize:13, bold:true, color:C.white, align:'center', valign:'middle', margin:0 });
    s.addText(items[i][1], { x:0.6+col*6.4, y, w:5.25, h:0.72, fontSize:12.5, color:C.offWhite, valign:'middle', margin:{ left:8 } });
  }
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 – EPIDEMIOLOGY
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  accentBar(s, C.teal, 0, 0.07);
  sectionTag(s, 'EPIDEMIOLOGY');
  slideTitle(s, 'Global Burden & Epidemiology');
  dividerLine(s);

  // Stat boxes
  const stats = [
    { val:'~13M', label:'New strokes/year\nglobally', color:C.cyan },
    { val:'~5.5M', label:'Annual stroke deaths\n(#2 cause of death)', color:C.orange },
    { val:'80%', label:'All strokes are\nischemic', color:C.green },
    { val:'1.9M', label:'Neurons lost per\nminute of ischemia', color:C.yellow },
  ];
  stats.forEach((st, i) => {
    const x = 0.4 + i * 3.1;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y:1.45, w:2.9, h:1.5, fill:{color:'122E50'}, line:{color:st.color, w:2}, rectRadius:0.12 });
    s.addText(st.val, { x, y:1.5, w:2.9, h:0.75, fontSize:32, bold:true, color:st.color, align:'center' });
    s.addText(st.label, { x, y:2.2, w:2.9, h:0.65, fontSize:11, color:C.offWhite, align:'center', lineSpacingMultiple:1.3 });
  });

  // Key facts
  s.addText('Key Epidemiological Facts', { x:0.4, y:3.15, w:6.5, h:0.4, fontSize:14, bold:true, color:C.cyan });
  const facts = [
    'Stroke is the 2nd leading cause of death and 3rd leading cause of disability-adjusted life years (DALYs) worldwide',
    'Incidence increases with age; doubles each decade after age 55',
    'In India, stroke incidence: 105–152/100,000/year; hemorrhagic stroke more common than in Western populations',
    'Recurrence risk: ~10% in first year; highest in first 48–72 hours after TIA',
    'Only ~20–30% of eligible patients receive IV tPA; thrombectomy access remains limited in LMICs',
  ];
  s.addText(facts.map(f => ({ text: f, options: { bullet:{type:'bullet', code:'25BA'}, breakLine:true, color:C.offWhite, fontSize:11.5, paraSpaceAfter:4 } })).concat([]), { x:0.4, y:3.55, w:7.5, h:3.3, fontSize:11.5, color:C.offWhite, lineSpacingMultiple:1.4 });
  // Right panel
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:8.3, y:3.15, w:4.6, h:3.95, fill:{color:'0A2040'}, line:{color:C.teal, w:1.5}, rectRadius:0.12 });
  s.addText('FAST Acronym', { x:8.5, y:3.3, w:4.2, h:0.4, fontSize:13, bold:true, color:C.yellow, align:'center' });
  const fast = [['F','ACIAL drooping — one side of face droops'],['A','RM weakness — one arm drifts down'],['S','PEECH slurred — garbled or strange speech'],['T','IME — call emergency services immediately']];
  fast.forEach(([letter, text], i) => {
    s.addShape(pres.shapes.ELLIPSE, { x:8.6, y:3.85+i*0.75, w:0.4, h:0.4, fill:{color:C.red}, line:{color:C.red} });
    s.addText(letter, { x:8.6, y:3.85+i*0.75, w:0.4, h:0.4, fontSize:13, bold:true, color:C.white, align:'center', valign:'middle', margin:0 });
    s.addText(text, { x:9.1, y:3.85+i*0.75, w:3.6, h:0.45, fontSize:11, color:C.offWhite, valign:'middle' });
  });
  footnote(s, 'Sources: Harrison\'s Principles of Internal Medicine 22E (2025); GBD 2021 Stroke Collaborators; API Textbook of Medicine');
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 – DEFINITION & CLASSIFICATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  accentBar(s, C.teal, 0, 0.07);
  sectionTag(s, 'CLASSIFICATION');
  slideTitle(s, 'Definition & TOAST Classification');
  dividerLine(s);

  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:1.45, w:12.5, h:0.8, fill:{color:'122E50'}, line:{color:C.cyan, w:1.5}, rectRadius:0.1 });
  s.addText([
    { text:'STROKE: ', options:{bold:true, color:C.cyan, fontSize:13} },
    { text:'A sudden-onset neurological deficit due to focal brain ischemia lasting >24 hours, or any duration if imaging shows infarction. Ischemic stroke accounts for ~80% of all strokes.', options:{color:C.offWhite, fontSize:13} }
  ], { x:0.55, y:1.5, w:12.2, h:0.7, valign:'middle' });

  s.addText('TOAST Classification of Ischemic Stroke Etiology', { x:0.4, y:2.4, w:12.5, h:0.4, fontSize:14, bold:true, color:C.yellow });

  const toast = [
    { type:'Large-Artery Atherosclerosis', pct:'~20%', desc:'Stenosis >50% of major cervical or intracranial artery; cortical or cerebellar infarct >1.5 cm. Mechanism: artery-to-artery embolism or in-situ thrombosis.', color:C.cyan },
    { type:'Cardioembolism', pct:'~20%', desc:'AF, valvular disease, MI, cardiomyopathy, PFO. Typically large cortical infarcts. High recurrence risk. Anticoagulation indicated for most.', color:C.orange },
    { type:'Small-Vessel Occlusion (Lacunar)', pct:'~25%', desc:'Infarct <1.5 cm in internal capsule, basal ganglia, thalamus, pons. Pure motor, pure sensory, ataxic-hemiparesis, dysarthria-clumsy hand syndromes.', color:C.green },
    { type:'Other Determined Etiology', pct:'~5%', desc:'Dissection, hypercoagulable states, vasculitis, CADASIL, air embolism, sickle cell disease, paradoxical embolism.', color:C.yellow },
    { type:'Cryptogenic (Undetermined)', pct:'~30%', desc:'No definite cause found despite adequate workup. May include Embolic Stroke of Undetermined Source (ESUS) — warrants extended cardiac monitoring.', color:C.mutedText },
  ];

  toast.forEach((t, i) => {
    const y = 2.9 + i * 0.87;
    s.addShape(pres.shapes.RECTANGLE, { x:0.4, y, w:0.08, h:0.72, fill:{color:t.color}, line:{color:t.color} });
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.52, y, w:12.35, h:0.72, fill:{color:'0A2040'}, line:{color:'1A3A5C', w:1}, rectRadius:0.06 });
    s.addText(`${t.type}  (${t.pct})`, { x:0.65, y, w:4.3, h:0.36, fontSize:12, bold:true, color:t.color, valign:'bottom' });
    s.addText(t.desc, { x:0.65, y:y+0.34, w:12.1, h:0.36, fontSize:10.5, color:C.offWhite, valign:'top' });
  });
  footnote(s, 'Adams HP et al. TOAST criteria. Stroke 1993. Harrison\'s 22E p.3479');
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 – PATHOPHYSIOLOGY
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  accentBar(s, C.teal, 0, 0.07);
  sectionTag(s, 'PATHOPHYSIOLOGY');
  slideTitle(s, 'Pathophysiology & The Ischemic Penumbra');
  dividerLine(s);

  // Left — penumbra concept
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:1.42, w:6.0, h:5.75, fill:{color:'0A2040'}, line:{color:C.teal, w:1.5}, rectRadius:0.12 });
  s.addText('Ischemic Penumbra Concept', { x:0.6, y:1.55, w:5.6, h:0.4, fontSize:13, bold:true, color:C.cyan });

  // Concentric circle diagram
  s.addShape(pres.shapes.ELLIPSE, { x:1.5, y:2.1, w:3.8, h:2.5, fill:{color:C.red, transparency:30}, line:{color:C.red, w:2} });
  s.addShape(pres.shapes.ELLIPSE, { x:2.05, y:2.45, w:2.7, h:1.8, fill:{color:C.orange, transparency:20}, line:{color:C.orange, w:2} });
  s.addShape(pres.shapes.ELLIPSE, { x:2.5, y:2.75, w:1.8, h:1.2, fill:{color:'8B1A1A'}, line:{color:'CC2200', w:1.5} });
  s.addText('CORE\n(irreversible)', { x:2.5, y:2.75, w:1.8, h:1.2, fontSize:9, bold:true, color:C.white, align:'center', valign:'middle' });
  s.addText('PENUMBRA\n(salvageable)', { x:2.05, y:2.45, w:2.7, h:0.55, fontSize:9, color:C.yellow, align:'center', italic:true });
  s.addText('Oligaemic zone\n(at-risk)', { x:1.55, y:2.1, w:3.8, h:0.55, fontSize:9, color:C.offWhite, align:'center', italic:true });

  const pathPoints = [
    'Normal CBF: 50–60 mL/100g/min',
    'Penumbra: CBF 10–20 mL — electrically silent but viable',
    'Infarct core: CBF <10 mL — irreversible within minutes',
    'Glutamate excitotoxicity → Ca²⁺ influx → cell death',
    'Free radical production, inflammatory cascade, apoptosis',
    'Penumbra is the therapeutic target for reperfusion',
    'Window for tPA: 0–4.5 hrs | Thrombectomy: up to 24 hrs (selected)',
  ];
  s.addText(pathPoints.map((p,i) => ({ text:p, options:{ bullet:{type:'bullet', code:'25BA'}, breakLine:i<pathPoints.length-1, fontSize:11, color:i===pathPoints.length-1?C.yellow:C.offWhite, paraSpaceAfter:3 } })), { x:0.55, y:4.75, w:5.7, h:2.25, lineSpacingMultiple:1.35 });

  // Right — cascade
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:6.7, y:1.42, w:6.2, h:5.75, fill:{color:'0A2040'}, line:{color:C.orange, w:1.5}, rectRadius:0.12 });
  s.addText('Molecular Cascade of Ischemic Injury', { x:6.9, y:1.55, w:5.8, h:0.4, fontSize:13, bold:true, color:C.orange });

  const cascade = [
    { step:'Arterial occlusion', desc:'Thrombosis/embolism → cessation of blood flow', color:C.red },
    { step:'Energy failure', desc:'ATP depletion within 1–2 minutes; Na⁺/K⁺ ATPase fails', color:C.orange },
    { step:'Ionic imbalance', desc:'Na⁺/Ca²⁺ influx, cellular swelling, depolarization', color:C.yellow },
    { step:'Excitotoxicity', desc:'Glutamate release → NMDA/AMPA receptor activation → Ca²⁺ overload', color:C.green },
    { step:'Free radicals', desc:'ROS/RNS production → lipid peroxidation, DNA damage', color:C.cyan },
    { step:'Inflammation', desc:'Microglial activation, cytokine release, BBB disruption', color:C.mutedText },
    { step:'Apoptosis/Necrosis', desc:'Final cell death; edema; hemorrhagic transformation risk', color:C.red },
  ];
  cascade.forEach((c, i) => {
    const y = 2.05 + i * 0.72;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:6.9, y, w:5.8, h:0.6, fill:{color:'122E50'}, line:{color:c.color, w:1}, rectRadius:0.06 });
    if (i < cascade.length-1) {
      s.addText('↓', { x:9.5, y:y+0.58, w:0.4, h:0.14, fontSize:9, color:C.mutedText, align:'center', margin:0 });
    }
    s.addText(c.step, { x:7.0, y, w:2.0, h:0.6, fontSize:10.5, bold:true, color:c.color, valign:'middle' });
    s.addText(c.desc, { x:9.05, y, w:3.55, h:0.6, fontSize:10, color:C.offWhite, valign:'middle', lineSpacingMultiple:1.2 });
  });
  footnote(s, 'Harrison\'s 22E: "PATHOPHYSIOLOGY OF ISCHEMIC STROKE" p.3477; CBF = cerebral blood flow; BBB = blood-brain barrier');
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 – ETIOLOGY & RISK FACTORS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  accentBar(s, C.teal, 0, 0.07);
  sectionTag(s, 'ETIOLOGY');
  slideTitle(s, 'Etiology & Risk Factors');
  dividerLine(s);

  // Modifiable risk factors
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:1.45, w:6.0, h:5.7, fill:{color:'0A2040'}, line:{color:C.cyan, w:1.5}, rectRadius:0.1 });
  s.addText('Modifiable Risk Factors', { x:0.6, y:1.58, w:5.6, h:0.38, fontSize:13, bold:true, color:C.cyan });

  const modifiable = [
    { rf:'Hypertension', note:'Most important; >50% attributable risk' },
    { rf:'Atrial Fibrillation', note:'5× risk increase; 15–20% of ischemic strokes' },
    { rf:'Diabetes Mellitus', note:'2–4× risk; accelerates atherosclerosis' },
    { rf:'Dyslipidemia', note:'High LDL → carotid/intracranial atherosclerosis' },
    { rf:'Smoking', note:'2× risk; synergistic with OCP' },
    { rf:'Obesity / Physical Inactivity', note:'Metabolic syndrome promotes all causes' },
    { rf:'Carotid Stenosis', note:'>70% stenosis: 2-year stroke risk ~26% untreated' },
    { rf:'Cardiac Disease', note:'LV thrombus, valvular disease, recent MI' },
    { rf:'OSA', note:'Hypoxia, BP surge; independent risk factor' },
    { rf:'Oral Contraceptives', note:'Especially in smokers with migraine with aura' },
  ];
  modifiable.forEach((m, i) => {
    const y = 2.05 + i * 0.5;
    s.addShape(pres.shapes.RECTANGLE, { x:0.7, y:y+0.06, w:0.28, h:0.28, fill:{color:C.cyan}, line:{color:C.cyan} });
    s.addText(`${m.rf}: `, { x:1.1, y, w:1.8, h:0.42, fontSize:11.5, bold:true, color:C.cyan, valign:'middle' });
    s.addText(m.note, { x:2.85, y, w:3.35, h:0.42, fontSize:10.5, color:C.offWhite, valign:'middle' });
  });

  // Non-modifiable
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:6.7, y:1.45, w:6.2, h:2.55, fill:{color:'0A2040'}, line:{color:C.yellow, w:1.5}, rectRadius:0.1 });
  s.addText('Non-Modifiable Risk Factors', { x:6.9, y:1.58, w:5.8, h:0.38, fontSize:13, bold:true, color:C.yellow });
  const nonmod = ['Age (risk doubles per decade >55)', 'Sex (M>F until age 75; F>M thereafter)', 'Race/Ethnicity (higher in Black, South Asian populations)', 'Family history / genetic predisposition', 'Prior stroke or TIA (highest recurrence risk in 1st 48h)'];
  s.addText(nonmod.map((n,i) => ({text:n, options:{bullet:true, breakLine:i<nonmod.length-1, fontSize:11, color:C.offWhite, paraSpaceAfter:3}})), { x:6.9, y:2.05, w:5.8, h:1.8 });

  // Less common causes
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:6.7, y:4.15, w:6.2, h:2.95, fill:{color:'0A2040'}, line:{color:C.orange, w:1.5}, rectRadius:0.1 });
  s.addText('Less Common / Rare Causes', { x:6.9, y:4.28, w:5.8, h:0.38, fontSize:13, bold:true, color:C.orange });
  const rare = [
    'Arterial dissection (carotid/vertebral) — trauma, Marfan, FMD',
    'Hypercoagulable states (antiphospholipid syndrome, protein C/S deficiency)',
    'Vasculitis (CNS vasculitis, SLE, PAN, Takayasu)',
    'CADASIL (NOTCH3 mutation — leukoaraiosis + migraines)',
    'Sickle cell disease — cerebral vasculopathy',
    'Illicit drugs — cocaine, amphetamines → vasospasm',
    'Paradoxical embolism via PFO',
  ];
  s.addText(rare.map((r,i) => ({text:r, options:{bullet:true, breakLine:i<rare.length-1, fontSize:10.5, color:C.offWhite, paraSpaceAfter:3}})), { x:6.9, y:4.7, w:5.8, h:2.3 });

  footnote(s, 'Harrison\'s 22E p.3477–3480; CMDT; API Textbook of Medicine; FMD=fibromuscular dysplasia');
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 – CLINICAL PRESENTATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  accentBar(s, C.teal, 0, 0.07);
  sectionTag(s, 'CLINICAL FEATURES');
  slideTitle(s, 'Clinical Presentation & Stroke Syndromes');
  dividerLine(s);

  // General features
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:1.42, w:5.5, h:3.3, fill:{color:'0A2040'}, line:{color:C.cyan, w:1.5}, rectRadius:0.1 });
  s.addText('Cardinal Features of Stroke', { x:0.6, y:1.55, w:5.1, h:0.38, fontSize:13, bold:true, color:C.cyan });
  const cardinal = [
    'Sudden onset — hallmark feature (maximal at onset)',
    'Hemiparesis / hemiplegia (85% of ischemic strokes)',
    'Hemisensory loss — numbness, paresthesia',
    'Aphasia — Broca\'s (expressive), Wernicke\'s (receptive)',
    'Dysarthria — slurred speech without language deficit',
    'Visual field defects — homonymous hemianopia',
    'Diplopia, vertigo, ataxia — posterior circulation',
    'Neglect / anosognosia — non-dominant hemisphere',
    'Headache — sudden, severe suggests SAH; may occur in AIS',
    'Impaired consciousness — suggests large hemisphere or brainstem',
  ];
  s.addText(cardinal.map((c,i) => ({text:c, options:{bullet:{type:'bullet', code:'25CF'}, breakLine:i<cardinal.length-1, fontSize:10.5, color:C.offWhite, paraSpaceAfter:2}})), { x:0.55, y:2.0, w:5.2, h:2.6 });

  // Stroke syndromes table
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:6.1, y:1.42, w:6.8, h:3.3, fill:{color:'0A2040'}, line:{color:C.green, w:1.5}, rectRadius:0.1 });
  s.addText('Vascular Territory Syndromes', { x:6.3, y:1.55, w:6.4, h:0.38, fontSize:13, bold:true, color:C.green });

  const syndromes = [
    { vessel:'MCA (dominant)', features:'Contralateral hemiplegia (arm>leg), hemisensory loss, aphasia, hemianopia, gaze deviation ipsilateral' },
    { vessel:'MCA (non-dominant)', features:'Contralateral hemiplegia, hemineglect, constructional apraxia, anosognosia, flat affect' },
    { vessel:'ACA', features:'Leg>arm weakness, abulia, apraxia, frontal release signs, urinary incontinence' },
    { vessel:'PCA', features:'Contralateral hemianopia, memory loss, alexia without agraphia (dominant), cortical blindness' },
    { vessel:'Basilar artery', features:'"Locked-in" syndrome, quadriplegia, cranial nerve palsies, coma — LIFE-THREATENING' },
    { vessel:'PICA (Wallenberg)', features:'Ipsilateral face + contralateral body sensory loss, Horner\'s, dysphagia, vertigo, ataxia' },
    { vessel:'Lacunar (internal capsule)', features:'Pure motor hemiparesis — face, arm, leg equally; no cortical signs' },
  ];
  s.addText([
    {text:'Territory', options:{bold:true, color:C.green, fontSize:10.5}},
    {text:'\t\t\t', options:{color:C.white, fontSize:10.5}},
    {text:'Clinical Features', options:{bold:true, color:C.green, fontSize:10.5}}
  ], {x:6.3, y:1.98, w:6.5, h:0.3});
  syndromes.forEach((syn, i) => {
    const y = 2.32 + i * 0.46;
    const bg = i % 2 === 0 ? '0E2845' : '122E50';
    s.addShape(pres.shapes.RECTANGLE, { x:6.15, y, w:6.7, h:0.44, fill:{color:bg}, line:{color:bg} });
    s.addText(syn.vessel, { x:6.2, y, w:2.4, h:0.44, fontSize:10, bold:true, color:C.cyan, valign:'middle' });
    s.addText(syn.features, { x:8.65, y, w:4.1, h:0.44, fontSize:9.5, color:C.offWhite, valign:'middle', lineSpacingMultiple:1.1 });
  });

  // NIHSS
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:4.85, w:12.5, h:2.3, fill:{color:'0A2040'}, line:{color:C.yellow, w:1.5}, rectRadius:0.1 });
  s.addText('NIH Stroke Scale (NIHSS) — Severity Scoring', { x:0.6, y:4.98, w:8, h:0.38, fontSize:13, bold:true, color:C.yellow });
  const nihss = [
    { range:'0', cat:'No stroke symptoms' },
    { range:'1–4', cat:'Minor stroke' },
    { range:'5–15', cat:'Moderate stroke' },
    { range:'16–20', cat:'Moderate-severe' },
    { range:'21–42', cat:'Severe stroke' },
  ];
  nihss.forEach((n, i) => {
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.6+i*2.4, y:5.42, w:2.2, h:1.45, fill:{color:'122E50'}, line:{color:C.yellow, w:1}, rectRadius:0.08 });
    s.addText(n.range, { x:0.6+i*2.4, y:5.5, w:2.2, h:0.55, fontSize:20, bold:true, color:C.yellow, align:'center' });
    s.addText(n.cat, { x:0.6+i*2.4, y:6.02, w:2.2, h:0.72, fontSize:11, color:C.offWhite, align:'center', lineSpacingMultiple:1.2 });
  });
  s.addText('NIHSS domains: Level of consciousness, gaze, visual fields, facial palsy, motor (arm/leg), limb ataxia, sensory, language/aphasia, dysarthria, extinction/neglect (total 15 items, max score 42)', { x:12.6+0.6+5*2.4-12.6, y:5.0, w:0.1, h:0.1, fontSize:0.1, color:C.navy });
  s.addText('NIHSS assesses: LOC, gaze, visual fields, facial palsy, motor arm/leg, ataxia, sensory, aphasia, dysarthria, neglect (max 42)', { x:0.55, y:4.98+0.45, w:12, h:0.35, fontSize:10, color:C.offWhite, italic:true });

  footnote(s, 'Harrison\'s 22E p.3471–3477; MCA=middle cerebral artery; ACA=anterior cerebral artery; PCA=posterior cerebral artery; PICA=posterior inferior cerebellar artery');
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 – DIAGNOSTIC APPROACH
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  accentBar(s, C.teal, 0, 0.07);
  sectionTag(s, 'DIAGNOSIS');
  slideTitle(s, 'Diagnostic Approach & Imaging');
  dividerLine(s);

  // Immediate workup
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:1.42, w:5.6, h:5.7, fill:{color:'0A2040'}, line:{color:C.orange, w:1.5}, rectRadius:0.1 });
  s.addText('Immediate Evaluation (Door-to-CT: <25 min)', { x:0.6, y:1.55, w:5.2, h:0.5, fontSize:12.5, bold:true, color:C.orange, lineSpacingMultiple:1.2 });

  const immediate = [
    { step:'History', detail:'Time of onset (last known well), anticoagulants, platelets, prior stroke, hypertension, DM, cardiac disease' },
    { step:'Exam', detail:'Vitals, NIHSS, blood glucose, ECG — look for AF/MI. Exclude mimics.' },
    { step:'CT Brain (non-contrast)', detail:'FIRST study. Rules out hemorrhage. Early ischemic changes (ASPECTS). Hyperdense artery sign.' },
    { step:'CT Angiography (CTA)', detail:'Head & neck: LVO detection (basilar, ICA, MCA M1). Critical for thrombectomy decision.' },
    { step:'CT Perfusion (CTP)', detail:'Core vs penumbra mismatch — guides late-window thrombectomy (6–24h). RAPID software.' },
    { step:'Labs', detail:'CBC, BMP, PT/INR, aPTT, glucose, LFTs, troponin. Type & screen if thrombolytics planned.' },
    { step:'MRI Brain (DWI/FLAIR)', detail:'Most sensitive for early ischemia (minutes). DWI bright = acute infarct. FLAIR helps age lesion.' },
  ];
  immediate.forEach((item, i) => {
    const y = 2.1 + i * 0.7;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.55, y, w:5.3, h:0.62, fill:{color:'122E50'}, line:{color:C.orange, w:0.7}, rectRadius:0.06 });
    s.addText(item.step, { x:0.65, y, w:1.4, h:0.62, fontSize:10.5, bold:true, color:C.orange, valign:'middle' });
    s.addText(item.detail, { x:2.1, y, w:3.65, h:0.62, fontSize:10, color:C.offWhite, valign:'middle', lineSpacingMultiple:1.1 });
  });

  // Imaging right panel
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:6.2, y:1.42, w:6.7, h:5.7, fill:{color:'0A2040'}, line:{color:C.cyan, w:1.5}, rectRadius:0.1 });
  s.addText('Neuroimaging — Key Concepts', { x:6.4, y:1.55, w:6.3, h:0.38, fontSize:13, bold:true, color:C.cyan });

  const imgConcepts = [
    { title:'ASPECTS Score (Alberta Stroke Program Early CT Score)', body:'10-point CT scoring system for MCA territory. Score 0–10. Score ≥6 associated with better outcome after thrombolysis. Score <6 suggests extensive ischemia — higher hemorrhage risk.' },
    { title:'DWI-FLAIR Mismatch', body:'DWI positive + FLAIR negative = lesion <4.5 hrs old → can guide tPA in "wake-up stroke" patients with unknown onset.' },
    { title:'CT Perfusion Mismatch (DAWN/DEFUSE-3)', body:'Ischemic core (rCBF<30%) vs total perfusion lesion. Mismatch ratio >1.8 or volume >15mL → benefit from thrombectomy up to 24 hours.' },
    { title:'Hyperdense MCA Sign', body:'Indicates thrombus in proximal MCA on plain CT. Positive predictive value ~90%. May be the only early CT finding.' },
    { title:'CTA — LVO Detection', body:'Large Vessel Occlusion (LVO): ICA terminus, MCA M1/M2, basilar artery. Presence of LVO mandates thrombectomy evaluation.' },
    { title:'Extended Workup (after stabilisation)', body:'MRI with MRA, cardiac monitoring (telemetry × 24h; Holter × 30 days for cryptogenic stroke), echocardiogram (TTE/TEE), carotid duplex ultrasound, thrombophilia screen if age <50.' },
  ];
  imgConcepts.forEach((ic, i) => {
    const y = 2.0 + i * 0.83;
    s.addShape(pres.shapes.RECTANGLE, { x:6.3, y:y+0.02, w:0.08, h:0.65, fill:{color:C.cyan}, line:{color:C.cyan} });
    s.addText(ic.title, { x:6.45, y, w:6.3, h:0.35, fontSize:10.5, bold:true, color:C.cyan });
    s.addText(ic.body, { x:6.45, y:y+0.32, w:6.3, h:0.48, fontSize:9.8, color:C.offWhite, lineSpacingMultiple:1.15 });
  });

  footnote(s, 'Harrison\'s 22E p.3481–3484; ASPECTS = Alberta Stroke Program Early CT Score; DWI = diffusion-weighted imaging; LVO = large vessel occlusion');
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 – IV THROMBOLYSIS (tPA)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  accentBar(s, C.red, 0, 0.07);
  sectionTag(s, 'THROMBOLYSIS', 0.35, 0.15);
  slideTitle(s, 'IV Thrombolysis — Alteplase (rt-PA)');
  dividerLine(s, 1.25, C.red);

  // Drug box
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:1.42, w:12.5, h:0.82, fill:{color:'2A0A0A'}, line:{color:C.red, w:2}, rectRadius:0.1 });
  s.addText([
    {text:'DOSE: ', options:{bold:true, color:C.red, fontSize:13.5}},
    {text:'Alteplase 0.9 mg/kg IV (max 90 mg) — 10% as IV bolus over 1 min, remaining 90% as infusion over 60 min', options:{color:C.white, fontSize:13}},
    {text:'    |    ', options:{color:C.mutedText, fontSize:13}},
    {text:'Tenecteplase 0.25 mg/kg IV (max 25 mg) single bolus — alternative (AHA 2019)', options:{color:C.offWhite, fontSize:12.5}}
  ], { x:0.55, y:1.5, w:12.2, h:0.68, valign:'middle' });

  // Columns
  // Inclusion
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:2.35, w:3.95, h:4.72, fill:{color:'0A2040'}, line:{color:C.green, w:1.5}, rectRadius:0.1 });
  s.addText('✓ Inclusion Criteria', { x:0.55, y:2.48, w:3.65, h:0.38, fontSize:12.5, bold:true, color:C.green });
  const incl = [
    'Age ≥18 years',
    'Clinical diagnosis of ischemic stroke',
    'Onset within 4.5 hours (or last known well)',
    'NIHSS ≥4 (or disabling deficit)',
    'CT: no hemorrhage, no hypodensity >1/3 MCA territory',
    'BP: <185/110 mmHg at time of treatment (can treat)',
    'Blood glucose: 50–400 mg/dL',
  ];
  s.addText(incl.map((c,i) => ({text:c, options:{bullet:true, breakLine:i<incl.length-1, fontSize:11, color:C.offWhite, paraSpaceAfter:4}})), { x:0.55, y:2.9, w:3.65, h:4.0 });

  // Absolute contraindications
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:4.5, y:2.35, w:4.1, h:4.72, fill:{color:'0A2040'}, line:{color:C.red, w:1.5}, rectRadius:0.1 });
  s.addText('✗ Absolute Contraindications', { x:4.65, y:2.48, w:3.8, h:0.5, fontSize:12.5, bold:true, color:C.red, lineSpacingMultiple:1.1 });
  const abs = [
    'Prior intracranial hemorrhage',
    'Intracranial neoplasm, AVM, aneurysm',
    'Recent head trauma (< 3 months)',
    'Recent intracranial/spinal surgery (< 3 months)',
    'Active internal bleeding (excluding menses)',
    'Suspected aortic dissection',
    'Platelet count <100,000/mm³',
    'INR >1.7 or PT >15 sec (on warfarin)',
    'Heparin within 48h with elevated aPTT',
    'DOAC within 48h (unless coag tests normal)',
    'SBP >185 or DBP >110 (if uncontrolled)',
    'Blood glucose <50 or >400 mg/dL',
  ];
  s.addText(abs.map((c,i) => ({text:c, options:{bullet:{type:'bullet', code:'25CF'}, breakLine:i<abs.length-1, fontSize:10.5, color:C.offWhite, paraSpaceAfter:3}})), { x:4.65, y:3.0, w:3.8, h:3.95 });

  // Relative contraindications & monitoring
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:8.75, y:2.35, w:4.15, h:2.3, fill:{color:'0A2040'}, line:{color:C.yellow, w:1.5}, rectRadius:0.1 });
  s.addText('Relative Contraindications (discuss)', { x:8.9, y:2.48, w:3.85, h:0.5, fontSize:12, bold:true, color:C.yellow, lineSpacingMultiple:1.1 });
  const rel = ['Mild/rapidly improving stroke (NIHSS ≤3)', 'Major surgery within 14 days', 'GI/GU bleed within 21 days', 'Post-MI pericarditis', 'Pregnancy', 'Age >80 (no absolute contraindication; extended window may not apply)'];
  s.addText(rel.map((r,i) => ({text:r, options:{bullet:true, breakLine:i<rel.length-1, fontSize:10, color:C.offWhite, paraSpaceAfter:2}})), { x:8.9, y:2.98, w:3.85, h:1.55 });

  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:8.75, y:4.75, w:4.15, h:2.28, fill:{color:'0A2040'}, line:{color:C.cyan, w:1.5}, rectRadius:0.1 });
  s.addText('Post-tPA Monitoring', { x:8.9, y:4.88, w:3.85, h:0.38, fontSize:12, bold:true, color:C.cyan });
  const mon = ['ICU/Stroke Unit admission', 'BP <180/105 for 24 hrs post-tPA', 'Neuro checks q15min × 2h, q30min × 6h, q1h × 16h', 'No anticoagulants/antiplatelets × 24h', 'Repeat CT at 24h before antiplatelets', 'Watch for: symptomatic ICH (6% risk), angioedema'];
  s.addText(mon.map((m,i) => ({text:m, options:{bullet:true, breakLine:i<mon.length-1, fontSize:10, color:C.offWhite, paraSpaceAfter:2}})), { x:8.9, y:5.3, w:3.85, h:1.6 });

  footnote(s, 'Harrison\'s 22E p.3484–3488; AHA/ASA 2019 Guidelines; NINDS rt-PA Trial; ECASS-III; alteplase = recombinant tissue plasminogen activator');
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 – MECHANICAL THROMBECTOMY
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  accentBar(s, C.teal, 0, 0.07);
  sectionTag(s, 'THROMBECTOMY');
  slideTitle(s, 'Mechanical Thrombectomy (EVT)');
  dividerLine(s);

  // Top banner
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:1.42, w:12.5, h:0.72, fill:{color:'0A2040'}, line:{color:C.cyan, w:1.5}, rectRadius:0.1 });
  s.addText([
    {text:'KEY PRINCIPLE: ', options:{bold:true, color:C.cyan, fontSize:13}},
    {text:'EVT is the most effective acute stroke treatment for LVO. NNT=2.6 (MR CLEAN, SWIFT PRIME, ESCAPE, EXTEND-IA, THRACE trials). Standard of care for anterior circulation LVO.', options:{color:C.offWhite, fontSize:12.5}}
  ], { x:0.55, y:1.52, w:12.2, h:0.55, valign:'middle' });

  // Selection criteria
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:2.25, w:5.9, h:4.2, fill:{color:'0A2040'}, line:{color:C.green, w:1.5}, rectRadius:0.1 });
  s.addText('Patient Selection Criteria', { x:0.6, y:2.38, w:5.5, h:0.38, fontSize:13, bold:true, color:C.green });
  const evtCrit = [
    { label:'Vessel', val:'Confirmed LVO on CTA (ICA, MCA M1, basilar)' },
    { label:'Time (early)', val:'Onset to groin puncture ≤6 hours (all patients with LVO)' },
    { label:'Time (late)', val:'6–24h: DAWN (CTP/DWI mismatch) or DEFUSE-3 (perfusion mismatch) criteria' },
    { label:'Baseline', val:'Pre-stroke mRS 0–1 (functionally independent)' },
    { label:'NIHSS', val:'≥6 for anterior circulation; lower threshold for basilar' },
    { label:'Imaging', val:'ASPECTS ≥6 (early window); or mismatch on perfusion imaging (late window)' },
    { label:'Age', val:'No strict age cutoff; benefit seen even in age >80' },
    { label:'tPA', val:'Give IV tPA if eligible even if proceeding to thrombectomy ("drip and ship")' },
  ];
  evtCrit.forEach((e, i) => {
    const y = 2.85 + i * 0.45;
    s.addText(`${e.label}: `, { x:0.6, y, w:1.5, h:0.42, fontSize:11, bold:true, color:C.green, valign:'middle' });
    s.addText(e.val, { x:2.15, y, w:3.95, h:0.42, fontSize:10.5, color:C.offWhite, valign:'middle', lineSpacingMultiple:1.1 });
  });

  // Procedure
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:6.5, y:2.25, w:6.4, h:4.2, fill:{color:'0A2040'}, line:{color:C.cyan, w:1.5}, rectRadius:0.1 });
  s.addText('Procedure & Technical Aspects', { x:6.7, y:2.38, w:6.0, h:0.38, fontSize:13, bold:true, color:C.cyan });
  const proc = [
    { step:'Access', detail:'Femoral artery (primary); radial access increasingly used' },
    { step:'Device', detail:'Stent-retriever (Solitaire, Trevo) and/or aspiration catheter (direct aspiration — ADAPT technique)' },
    { step:'Anesthesia', detail:'Conscious sedation preferred (better outcomes vs GA in MR CLEAN, AnStroke). Use GA if airway at risk.' },
    { step:'Endpoint', detail:'TICI 2b/3 (Thrombolysis In Cerebral Infarction scale — complete or near-complete reperfusion)' },
    { step:'Success', detail:'TICI 2b/3 achieved in ~80% of cases with modern devices' },
    { step:'Balloon GC', detail:'Balloon guide catheter reduces embolization, improves TICI grade' },
    { step:'Post-EVT', detail:'ICU admission, BP <160 if reperfused, DVT prophylaxis, dysphagia screen' },
    { step:'Basilar', detail:'Basilar artery thrombectomy up to 24h (BEST, BASICS trials) — strong indication even with severe deficit' },
  ];
  proc.forEach((p, i) => {
    const y = 2.85 + i * 0.45;
    const bg = i % 2 === 0 ? '0E2845' : '122E50';
    s.addShape(pres.shapes.RECTANGLE, { x:6.55, y, w:6.3, h:0.43, fill:{color:bg}, line:{color:bg} });
    s.addText(p.step, { x:6.6, y, w:1.3, h:0.43, fontSize:10.5, bold:true, color:C.cyan, valign:'middle' });
    s.addText(p.detail, { x:7.95, y, w:4.85, h:0.43, fontSize:10, color:C.offWhite, valign:'middle', lineSpacingMultiple:1.1 });
  });

  // Key trials
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:6.52, w:12.5, h:0.72, fill:{color:'0A2040'}, line:{color:C.yellow, w:1.5}, rectRadius:0.1 });
  s.addText([
    {text:'Landmark Trials: ', options:{bold:true, color:C.yellow, fontSize:12}},
    {text:'MR CLEAN (2015) | SWIFT PRIME | ESCAPE | EXTEND-IA | THRACE → NNT ≈ 2.6 for functional independence  |  DAWN (6–24h) | DEFUSE-3 (6–16h) → extended window  |  BASICS (basilar 2021)', options:{color:C.offWhite, fontSize:11}}
  ], { x:0.55, y:6.6, w:12.2, h:0.58, valign:'middle' });

  footnote(s, 'Harrison\'s 22E p.3488–3492; AHA/ASA 2019 EVT Guidelines; LVO=large vessel occlusion; TICI=Thrombolysis in Cerebral Infarction scale; GA=general anaesthesia');
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 11 – GENERAL & SUPPORTIVE CARE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  accentBar(s, C.teal, 0, 0.07);
  sectionTag(s, 'SUPPORTIVE CARE');
  slideTitle(s, 'General & Supportive Management');
  dividerLine(s);

  const domains = [
    {
      title:'Blood Pressure Management',
      color:C.red,
      points:[
        'Pre-tPA: Lower to <185/110 before giving tPA (labetalol, nicardipine, clevidipine)',
        'Post-tPA: Maintain BP <180/105 for 24 hours',
        'No tPA given: Permissive hypertension — do NOT treat unless BP >220/120 or end-organ damage',
        'Avoid aggressive lowering — may extend ischemic penumbra',
        'Post-EVT (reperfused): Target BP <160/90 to prevent reperfusion injury',
      ]
    },
    {
      title:'Blood Glucose & Temperature',
      color:C.orange,
      points:[
        'Hyperglycemia (>180 mg/dL) worsens outcomes — treat with insulin infusion (target 140–180)',
        'Hypoglycemia (<60 mg/dL) mimics stroke — must be corrected immediately before thrombolysis',
        'Fever (>37.5°C) worsens neurological outcomes — aggressive antipyresis (paracetamol, cooling)',
        'Therapeutic hypothermia: not proven in AIS; under investigation',
      ]
    },
    {
      title:'Airway, Breathing, Circulation',
      color:C.cyan,
      points:[
        'SpO₂ >94% — supplemental O₂ only if hypoxic (routine O₂ not beneficial)',
        'Intubation if: GCS ≤8, airway loss, respiratory failure',
        'Head of bed: 0–30° in first 24h (avoid head-of-bed elevation in early AIS — reduces cerebral perfusion)',
        'IV access, cardiac monitoring, continuous pulse oximetry',
      ]
    },
    {
      title:'Cerebral Edema & ICP',
      color:C.yellow,
      points:[
        'Malignant MCA infarction: massive edema peaks 48–96h, herniation risk',
        'Hemicraniectomy within 48h for large MCA infarcts (age <60 with dominant/non-dominant hemisphere) — DECIMAL, DESTINY, HAMLET trials',
        'Osmotherapy: Mannitol 1 g/kg IV, hypertonic saline (3%)  for herniation signs',
        'Avoid corticosteroids — increase infection risk without benefit in AIS',
      ]
    },
    {
      title:'DVT & Complication Prophylaxis',
      color:C.green,
      points:[
        'Early mobilization reduces DVT; pneumatic compression devices within 24h',
        'LMWH/heparin DVT prophylaxis: after 24h if no hemorrhagic transformation on repeat CT',
        'Dysphagia screen before oral intake (aspiration pneumonia risk — major cause of stroke mortality)',
        'Avoid urinary catheters where possible; treat UTI and pneumonia promptly',
        'Pressure ulcer prevention, bowel care, fall prevention',
      ]
    },
    {
      title:'Nutrition & Other Care',
      color:C.mutedText,
      points:[
        'NGT feeding if dysphagia confirmed (PEG if prolonged — delay >7 days)',
        'Bladder care, pressure relief, early physiotherapy consult',
        'Depression common post-stroke — screen and treat (SSRIs)',
        'Seizure management: treat clinical seizures; prophylactic AEDs not routinely recommended',
      ]
    },
  ];

  const perCol = 3;
  domains.forEach((d, i) => {
    const col = Math.floor(i / perCol);
    const row = i % perCol;
    const x = 0.4 + col * 6.45;
    const y = 1.42 + row * 2.0;
    const h = 1.88;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w:6.15, h, fill:{color:'0A2040'}, line:{color:d.color, w:1.5}, rectRadius:0.1 });
    s.addShape(pres.shapes.RECTANGLE, { x, y, w:6.15, h:0.42, fill:{color:d.color, transparency:70}, line:{color:d.color} });
    s.addText(d.title, { x:x+0.15, y, w:5.85, h:0.42, fontSize:11.5, bold:true, color:d.color, valign:'middle' });
    s.addText(d.points.map((p,j) => ({text:p, options:{bullet:true, breakLine:j<d.points.length-1, fontSize:9.8, color:C.offWhite, paraSpaceAfter:2}})), { x:x+0.12, y:y+0.44, w:5.9, h:h-0.5, lineSpacingMultiple:1.2 });
  });

  footnote(s, 'Harrison\'s 22E p.3493–3497; CMDT 2025; API Textbook of Medicine; BP targets from AHA/ASA 2019 Guidelines');
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 12 – SECONDARY PREVENTION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  accentBar(s, C.teal, 0, 0.07);
  sectionTag(s, 'PREVENTION');
  slideTitle(s, 'Secondary Prevention of Ischemic Stroke');
  dividerLine(s);

  // Antithrombotic
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:1.42, w:6.0, h:5.7, fill:{color:'0A2040'}, line:{color:C.cyan, w:1.5}, rectRadius:0.1 });
  s.addText('Antithrombotic Therapy', { x:0.6, y:1.55, w:5.6, h:0.38, fontSize:13, bold:true, color:C.cyan });

  const antithromb = [
    { head:'Antiplatelet (non-cardioembolic stroke)', items:[
      'Aspirin 75–325 mg/day — first-line. Start within 24–48h of AIS.',
      'Aspirin + Clopidogrel for 21 days (POINT/CHANCE trial): minor stroke/high-risk TIA (NIHSS ≤3, ABCD2 ≥4)',
      'Clopidogrel 75 mg/day: aspirin intolerance, or after DAPT',
      'Ticagrelor (THALES trial): aspirin + ticagrelor × 30 days for non-lacunar, non-cardioembolic stroke',
      'Aspirin + Dipyridamole ER: alternative to clopidogrel for secondary prevention',
    ]},
    { head:'Anticoagulation (cardioembolic/AF stroke)', items:[
      'Atrial fibrillation: DOACs (apixaban, rivaroxaban, dabigatran) > warfarin (INR 2–3)',
      'Timing: start 4–14 days post-stroke (1–3–6–12 rule based on infarct size)',
      'LV thrombus, valvular AF: warfarin preferred',
      'PFO + cryptogenic stroke in young: ASA ± device closure (REDUCE, CLOSE, RESPECT trials)',
      'Cervical dissection: anticoagulation × 3–6 months then antiplatelet',
    ]},
  ];
  let yy = 2.05;
  antithromb.forEach(sec => {
    s.addText(sec.head, { x:0.55, y:yy, w:5.5, h:0.38, fontSize:11.5, bold:true, color:C.yellow, italic:true });
    yy += 0.38;
    sec.items.forEach((item, j) => {
      s.addShape(pres.shapes.RECTANGLE, { x:0.65, y:yy+0.07, w:0.22, h:0.22, fill:{color:C.cyan}, line:{color:C.cyan} });
      s.addText(item, { x:0.95, y:yy, w:5.25, h:0.44, fontSize:10, color:C.offWhite, valign:'middle', lineSpacingMultiple:1.1 });
      yy += 0.44;
    });
    yy += 0.15;
  });

  // Risk factor control
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:6.6, y:1.42, w:6.3, h:2.8, fill:{color:'0A2040'}, line:{color:C.orange, w:1.5}, rectRadius:0.1 });
  s.addText('Risk Factor Modification', { x:6.8, y:1.55, w:5.9, h:0.38, fontSize:13, bold:true, color:C.orange });
  const rfm = [
    'Hypertension: Target <130/80 (SBP). ACEI/ARB preferred; thiazides, CCBs also effective.',
    'Diabetes: HbA1c <7%. Metformin first-line; GLP-1 agonists offer CV protection.',
    'Dyslipidemia: High-intensity statin (atorvastatin 40–80 mg). Target LDL <1.8 mmol/L (70 mg/dL) or reduction ≥50%.',
    'Smoking cessation: Most effective single intervention — reduces stroke risk by 50% within 1 year.',
    'AF rhythm control: Rate vs rhythm control; ablation if symptomatic AF.',
    'Lifestyle: DASH/Mediterranean diet, BMI <25, aerobic exercise ≥30 min/day, alcohol moderation.',
  ];
  s.addText(rfm.map((r,i) => ({text:r, options:{bullet:{type:'bullet', code:'25BA'}, breakLine:i<rfm.length-1, fontSize:10.5, color:C.offWhite, paraSpaceAfter:3}})), { x:6.8, y:2.0, w:5.9, h:2.1 });

  // Carotid intervention
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:6.6, y:4.35, w:6.3, h:2.77, fill:{color:'0A2040'}, line:{color:C.green, w:1.5}, rectRadius:0.1 });
  s.addText('Carotid Intervention', { x:6.8, y:4.48, w:5.9, h:0.38, fontSize:13, bold:true, color:C.green });
  const carotid = [
    'Symptomatic carotid stenosis 70–99%: CEA within 2 weeks (NNT=6). CAS in selected patients.',
    'Symptomatic carotid stenosis 50–69%: CEA beneficial (NNT=22); early intervention preferred.',
    'Asymptomatic carotid stenosis >60%: CEA if surgical risk <3% and life expectancy >5 years (controversial).',
    'Intracranial atherosclerosis >70%: medical therapy preferred over PTAS (SAMMPRIS trial).',
    'Optimal medical therapy: statin + antiplatelet + risk factor control > aggressive stenting for most.',
  ];
  s.addText(carotid.map((c,i) => ({text:c, options:{bullet:true, breakLine:i<carotid.length-1, fontSize:10.5, color:C.offWhite, paraSpaceAfter:3}})), { x:6.8, y:5.0, w:5.9, h:2.0 });

  footnote(s, 'Harrison\'s 22E p.3500–3510; AHA/ASA Secondary Prevention Guidelines 2021; CHANCE, POINT, THALES trials; NASCET/ECST carotid trials');
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 13 – STROKE UNITS & REHABILITATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  accentBar(s, C.teal, 0, 0.07);
  sectionTag(s, 'REHABILITATION');
  slideTitle(s, 'Stroke Units & Rehabilitation');
  dividerLine(s);

  // Stroke unit benefits
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:1.42, w:5.8, h:2.85, fill:{color:'0A2040'}, line:{color:C.cyan, w:1.5}, rectRadius:0.1 });
  s.addText('Stroke Unit Care — Evidence Base', { x:0.6, y:1.55, w:5.4, h:0.38, fontSize:13, bold:true, color:C.cyan });
  const suPoints = [
    'Stroke unit care reduces mortality by 14% and dependency by 18% (Cochrane meta-analysis, NNT=18)',
    'Organized inpatient (stroke unit) care is the single most effective intervention for stroke outcome',
    'Multidisciplinary team: Neurology/Internal Medicine, Nursing, Physiotherapy, Occupational Therapy, Speech Therapy, Social Work',
    '"Time is Brain" protocols: door-to-CT <25 min, door-to-needle <60 min, door-to-groin <90 min',
    'Telestroke networks extend expert care to peripheral hospitals',
    'India: National Programme for Prevention & Control of CVD (NPCDCS); stroke ready hospital concept',
  ];
  s.addText(suPoints.map((p,i) => ({text:p, options:{bullet:true, breakLine:i<suPoints.length-1, fontSize:10.5, color:C.offWhite, paraSpaceAfter:3}})), { x:0.6, y:2.0, w:5.5, h:2.2 });

  // Rehabilitation
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:6.4, y:1.42, w:6.5, h:2.85, fill:{color:'0A2040'}, line:{color:C.green, w:1.5}, rectRadius:0.1 });
  s.addText('Neurorehabilitation', { x:6.6, y:1.55, w:6.1, h:0.38, fontSize:13, bold:true, color:C.green });
  const rehab = [
    'Begin within 24–48h of stroke (early mobilization reduces DVT, pneumonia, bedsores)',
    'Physiotherapy: gait retraining, balance, upper limb function, spasticity management',
    'Occupational therapy: ADL retraining, splinting, hand function, home modification',
    'Speech-language therapy: aphasia, dysarthria, dysphagia (compensatory + restorative strategies)',
    'Neuroplasticity: constraint-induced movement therapy, mirror therapy, task-specific training',
    'Robotic-assisted therapy, FES, tDCS/rTMS — emerging modalities',
    'Goal: maximize functional independence; discharge to community with support',
  ];
  s.addText(rehab.map((r,i) => ({text:r, options:{bullet:true, breakLine:i<rehab.length-1, fontSize:10.5, color:C.offWhite, paraSpaceAfter:3}})), { x:6.6, y:2.0, w:6.1, h:2.2 });

  // Prognosis
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.4, y:4.35, w:5.8, h:2.77, fill:{color:'0A2040'}, line:{color:C.yellow, w:1.5}, rectRadius:0.1 });
  s.addText('Prognosis & Outcome Predictors', { x:0.6, y:4.48, w:5.4, h:0.38, fontSize:13, bold:true, color:C.yellow });
  const prognosis = [
    '10–30% of stroke patients die within 30 days; ~30% have permanent moderate-severe disability',
    'Baseline NIHSS: strongest predictor of outcome (NIHSS ≥20 → poor prognosis)',
    'Age, prestroke functional status, stroke volume are key prognostic factors',
    'Time to reperfusion: earlier = better outcome (each 30-min delay → 15% less functional independence)',
    'Modified Rankin Scale (mRS): 0 (no symptoms) to 6 (death) — primary trial endpoint',
    'Recovery: 70% motor recovery occurs in 1st 3 months; ongoing recovery up to 1 year',
  ];
  s.addText(prognosis.map((p,i) => ({text:p, options:{bullet:true, breakLine:i<prognosis.length-1, fontSize:10.5, color:C.offWhite, paraSpaceAfter:3}})), { x:0.6, y:5.0, w:5.5, h:2.0 });

  // Special circumstances
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:6.4, y:4.35, w:6.5, h:2.77, fill:{color:'0A2040'}, line:{color:C.orange, w:1.5}, rectRadius:0.1 });
  s.addText('Special Circumstances', { x:6.6, y:4.48, w:6.1, h:0.38, fontSize:13, bold:true, color:C.orange });
  const special = [
    'Wake-up stroke (unknown onset): MRI DWI-FLAIR mismatch guides tPA decision (WAKE-UP trial)',
    'Stroke on anticoagulants: if INR <1.7 or last DOAC >48h (or normal coag), tPA may be given',
    'Stroke in pregnancy: IV tPA acceptable (risks similar); EVT preferred where available',
    'Stroke with COVID-19: hypercoagulable state; higher risk of LVO in younger patients',
    'Young stroke (<50 years): extensive workup — dissection, PFO, thrombophilia, CADASIL, vasculitis',
    'Basilar artery occlusion: high mortality without reperfusion; thrombectomy up to 24h justified',
    'TIA management: ABCD2 score; dual antiplatelet if NIHSS ≤3; urgent carotid/cardiac workup',
  ];
  s.addText(special.map((p,i) => ({text:p, options:{bullet:true, breakLine:i<special.length-1, fontSize:10.5, color:C.offWhite, paraSpaceAfter:3}})), { x:6.6, y:5.0, w:6.1, h:2.0 });

  footnote(s, 'Harrison\'s 22E p.3492–3499; Cochrane Stroke Unit Review; API Textbook of Medicine; WAKE-UP Trial (NEJM 2018)');
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 14 – KEY TAKEAWAYS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  navyBg(s);
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:0.22, h:7.5, fill:{color:C.teal}, line:{color:C.teal} });
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:6.9, w:13.3, h:0.6, fill:{color:C.teal}, line:{color:C.teal} });
  accentBar(s, C.teal, 0, 0.07);
  sectionTag(s, 'KEY TAKEAWAYS');
  slideTitle(s, 'Key Clinical Takeaways');
  dividerLine(s);

  const keys = [
    { num:'01', msg:'TIME IS BRAIN: 1.9 million neurons die every minute. Call emergency services immediately. Door-to-needle <60 min, door-to-groin <90 min.', color:C.red },
    { num:'02', msg:'Diagnose with non-contrast CT first (exclude hemorrhage), then CTA for LVO. MRI DWI is most sensitive for early ischemia.', color:C.cyan },
    { num:'03', msg:'IV Alteplase 0.9 mg/kg (max 90 mg) within 4.5 hours — check all inclusion/exclusion criteria; BP <185/110 before dosing.', color:C.orange },
    { num:'04', msg:'Mechanical thrombectomy for LVO — standard of care up to 6h (or 24h with perfusion mismatch). Best NNT of any acute stroke intervention (≈2.6).', color:C.green },
    { num:'05', msg:'Permissive hypertension in first 24h (no tPA): only treat BP >220/120. Post-tPA: maintain <180/105. Post-EVT (reperfused): <160.', color:C.yellow },
    { num:'06', msg:'Antiplatelet within 24–48h (after excluding hemorrhage on CT). Dual antiplatelet × 21 days for minor stroke/TIA (CHANCE/POINT protocol).', color:C.cyan },
    { num:'07', msg:'AF-related stroke: start DOAC 4–14 days post-stroke (1-3-6-12 day rule based on infarct size). DOACs preferred over warfarin.', color:C.orange },
    { num:'08', msg:'Stroke Unit + multidisciplinary rehab = single most effective intervention for functional outcome. Early mobilization within 24–48h.', color:C.green },
  ];

  const perCol = 4;
  keys.forEach((k, i) => {
    const col = Math.floor(i / perCol);
    const row = i % perCol;
    const x = 0.4 + col * 6.45;
    const y = 1.42 + row * 1.45;
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w:6.15, h:1.32, fill:{color:'0A2040'}, line:{color:k.color, w:1.5}, rectRadius:0.1 });
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x, y, w:0.65, h:1.32, fill:{color:k.color}, line:{color:k.color}, rectRadius:0.1 });
    s.addText(k.num, { x, y, w:0.65, h:1.32, fontSize:16, bold:true, color:C.navy, align:'center', valign:'middle', margin:0 });
    s.addText(k.msg, { x:x+0.72, y, w:5.35, h:1.32, fontSize:11, color:C.offWhite, valign:'middle', lineSpacingMultiple:1.3 });
  });

  s.addText('Harrison\'s Principles of Internal Medicine 22E (2025) | Current Medical Diagnosis & Treatment (CMDT) | API Textbook of Medicine', { x:0.4, y:7.08, w:12.5, h:0.3, fontSize:9, color:C.mutedText, italic:true, align:'center' });
}

// ══════════════════════════════════════════════════════════════════════════════
// WRITE FILE
// ══════════════════════════════════════════════════════════════════════════════
pres.writeFile({ fileName: '/home/daytona/workspace/acute-ischemic-stroke-ppt/Acute_Ischemic_Stroke_Management.pptx' })
  .then(() => console.log('✅ PPTX created successfully!'))
  .catch(err => console.error('❌ Error:', err));