Acute Ischemic Stroke¶

VERSION: 1.0 CREATED: January 21, 2026 REVISED: January 21, 2026 STATUS: Draft - Pending Review

DIAGNOSIS: Acute Ischemic Stroke

ICD-10: I63.9 (Cerebral infarction, unspecified); I63.50 (Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery); I63.30 (Cerebral infarction due to thrombosis of unspecified cerebral artery); I63.40 (Cerebral infarction due to embolism of unspecified cerebral artery); G45.9 (Transient cerebral ischemic attack, unspecified)

CLINICAL SYNONYMS: Acute ischemic stroke, AIS, brain attack, cerebrovascular accident, CVA, cerebral infarction, embolic stroke, thrombotic stroke, lacunar stroke, large vessel occlusion, LVO, cryptogenic stroke, ESUS (embolic stroke of undetermined source)

SCOPE: Emergency evaluation and treatment of acute ischemic stroke, including thrombolysis decision-making, mechanical thrombectomy candidacy, acute stroke unit care, secondary prevention, and etiologic workup. For hemorrhagic stroke, TIA, or venous sinus thrombosis, use dedicated templates.

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

SECTION A: ACTION ITEMS¶

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Point-of-care glucose	Hypoglycemia can mimic stroke; required before tPA	60-180 mg/dL	STAT	STAT	ROUTINE	STAT
CBC with differential	Baseline; thrombocytopenia contraindication to tPA	Platelets >100K	STAT	STAT	ROUTINE	STAT
PT/INR	Anticoagulation status; INR >1.7 contraindication to tPA	INR <1.7	STAT	STAT	ROUTINE	STAT
PTT	Baseline; heparin effect assessment	Normal	STAT	STAT	ROUTINE	STAT
Basic metabolic panel	Electrolytes, renal function	Normal	STAT	STAT	ROUTINE	STAT
Troponin	Concurrent MI; cardioembolic source	Normal	STAT	STAT	ROUTINE	STAT
BNP or NT-proBNP	Heart failure; atrial cardiopathy	Normal	URGENT	ROUTINE	ROUTINE	URGENT
Lipid panel (fasting preferred)	Cardiovascular risk; statin candidacy	LDL target <70	-	ROUTINE	ROUTINE	-
HbA1c	Diabetes as risk factor	<7% goal	-	ROUTINE	ROUTINE	-

1B. Extended Workup (Etiologic Evaluation)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
TSH	Thyroid disease and atrial fibrillation	Normal	-	ROUTINE	ROUTINE	-
LFTs	Baseline for statin therapy	Normal	-	ROUTINE	ROUTINE	-
Urine drug screen	Cocaine, amphetamine-induced stroke	Negative	URGENT	ROUTINE	ROUTINE	URGENT
Pregnancy test (females of childbearing age)	tPA risk assessment	Negative (or counsel risks)	STAT	STAT	ROUTINE	STAT
Hemoglobin A1c	Glycemic control assessment	<7% goal	-	ROUTINE	ROUTINE	-
ESR	Vasculitis screen	Normal	-	ROUTINE	ROUTINE	-
CRP	Inflammation; vasculitis	Normal	-	ROUTINE	ROUTINE	-
Homocysteine	Hypercoagulable workup in young stroke	Normal (<15 umol/L)	-	ROUTINE	ROUTINE	-
Vitamin B12	Hyperhomocysteinemia cause	Normal	-	ROUTINE	ROUTINE	-
Folate	Hyperhomocysteinemia cause	Normal	-	ROUTINE	ROUTINE	-

1C. Rare/Specialized (Young Stroke, Cryptogenic, Hypercoagulable)¶

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, anti-beta2 glycoprotein)	Hypercoagulable workup; repeat in 12 weeks if positive	Negative	-	EXT	ROUTINE	-
Protein C, Protein S, Antithrombin III	Inherited thrombophilia (defer acute phase; check 2-4 weeks post-stroke)	Normal	-	EXT	ROUTINE	-
Factor V Leiden, Prothrombin gene mutation	Inherited thrombophilia	Negative	-	EXT	ROUTINE	-
ANA, anti-dsDNA	Vasculitis, SLE	Negative	-	EXT	ROUTINE	-
ANCA (c-ANCA, p-ANCA)	Primary CNS vasculitis; systemic vasculitis	Negative	-	EXT	EXT	-
Syphilis serology (RPR)	Infectious vasculopathy	Negative	-	ROUTINE	ROUTINE	-
HIV antibody	HIV-associated vasculopathy	Negative	-	ROUTINE	ROUTINE	-
Hepatitis B and C serology	Associated with vasculitis	Negative	-	ROUTINE	ROUTINE	-
Lipoprotein(a)	Elevated in cryptogenic stroke	Normal (<50 nmol/L or <30 mg/dL)	-	EXT	ROUTINE	-
Sickle cell screen	If clinical suspicion	Negative	-	EXT	ROUTINE	-
Fabry disease testing (alpha-galactosidase A, GLA gene)	Young cryptogenic stroke, especially with other Fabry features	Normal enzyme activity	-	EXT	EXT	-

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line (Hyperacute)¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
Non-contrast CT head (NCCT)	STAT - door to CT <25 min target	No hemorrhage; early ischemic changes (ASPECTS score)	None	STAT	STAT	-	STAT
CT angiography head and neck (CTA)	STAT with NCCT	Large vessel occlusion (LVO); carotid/vertebral stenosis	Contrast allergy (premedicate), CKD (benefit usually outweighs risk in acute stroke)	STAT	STAT	-	STAT
CT perfusion (CTP)	If within extended window (6-24 hours) or wake-up stroke	Mismatch (ischemic penumbra salvageable)	Same as CTA	STAT	STAT	-	STAT
ECG (12-lead)	STAT	Atrial fibrillation, STEMI, LVH	None	STAT	STAT	ROUTINE	STAT

2B. Extended (Inpatient Etiologic Workup)¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI brain with DWI	Within 24 hours; better for small/posterior strokes	Acute infarct confirmation; lesion pattern	Pacemaker, metallic implants (check compatibility)	URGENT	STAT	ROUTINE	URGENT
MRA head and neck	With MRI if CTA not done	Stenosis, dissection, aneurysm	Same as MRI	URGENT	ROUTINE	ROUTINE	URGENT
Transthoracic echocardiogram (TTE) with bubble study	Within 24-48 hours	LV thrombus, PFO, valvular disease, wall motion abnormalities	None	-	ROUTINE	ROUTINE	-
Transesophageal echocardiogram (TEE)	If TTE non-diagnostic and high suspicion for cardiac source; or PFO evaluation	LAA thrombus, aortic atheroma, PFO with atrial septal aneurysm	Esophageal pathology	-	ROUTINE	ROUTINE	-
Carotid duplex ultrasound	If CTA/MRA not done or for follow-up	Stenosis >50%	None	-	ROUTINE	ROUTINE	-
Transcranial Doppler (TCD) with bubble study	PFO evaluation; vasospasm monitoring	Right-to-left shunt; microembolic signals	Inadequate acoustic windows	-	ROUTINE	ROUTINE	-
Continuous cardiac telemetry (minimum 24-72 hours)	Paroxysmal AF detection	Atrial fibrillation	None	STAT	STAT	-	STAT
Extended cardiac monitoring (Holter 7-30 days or implantable loop recorder)	Cryptogenic stroke; AF not detected on telemetry	Paroxysmal AF	None significant	-	ROUTINE	ROUTINE	-

2C. Rare/Specialized¶

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
Conventional cerebral angiography (DSA)	If vasculitis suspected; CNS vasculitis workup	Beading, stenosis, aneurysm	Contrast allergy, CKD, coagulopathy	-	EXT	EXT	-
High-resolution vessel wall MRI	Vasculitis, intracranial atherosclerosis characterization	Wall enhancement pattern	Same as MRI	-	EXT	EXT	-
Lumbar puncture	If vasculitis, infectious, or inflammatory etiology suspected	See LP section	See LP section	-	EXT	EXT	-
PET-CT or PET-MRI	Occult malignancy workup; giant cell arteritis	No malignancy/inflammation	Pregnancy	-	EXT	EXT	-
Implantable loop recorder (ILR)	Cryptogenic stroke after negative workup	Paroxysmal AF detection	Active infection	-	-	ROUTINE	-

LUMBAR PUNCTURE¶

Indication: Suspected CNS vasculitis, infectious etiology, or inflammatory condition; rarely needed in routine ischemic stroke

Timing: After brain imaging; not urgent unless infection suspected

Volume Required: 10-15 mL (standard diagnostic)

Study	ED	HOSP	OPD	Rationale	Target Finding
Opening pressure	-	EXT	EXT	Rule out elevated ICP	10-20 cm H2O
Cell count (tubes 1 and 4)	-	EXT	EXT	Vasculitis, infection	WBC <5, RBC 0
Protein	-	EXT	EXT	Inflammation	Normal 15-45 mg/dL
Glucose with serum glucose	-	EXT	EXT	Infection	Normal (>60% serum)
Gram stain and culture	-	EXT	EXT	Bacterial meningitis	No organisms
VDRL (CSF)	-	EXT	EXT	Neurosyphilis	Negative
Cytology	-	EXT	EXT	Malignancy	Negative

Contraindications: Coagulopathy (INR >1.5, platelets <50K); space-occupying lesion with mass effect

3. TREATMENT¶

3A. Acute/Emergent (Hyperacute Phase)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Alteplase (tPA) IV	IV	-	0.9 mg/kg :: IV :: once :: 0.9 mg/kg IV (max 90 mg); 10% as bolus over 1 min, remainder over 60 min; within 4.5 hours of symptom onset	See Appendix A for complete exclusion criteria; major: ICH, recent surgery, BP >185/110 despite treatment, INR >1.7, platelets <100K	Neuro checks q15min x 2h, then q30min x 6h, then q1h x 16h; BP q15min x 2h, then q30min x 6h; hold antiplatelets/anticoagulants 24h; CT head before anticoagulation	STAT	STAT	-	STAT
Tenecteplase IV	IV	-	0.25 mg/kg :: IV :: once :: 0.25 mg/kg IV bolus (max 25 mg); single bolus (no infusion); within 4.5 hours of symptom onset	Same as alteplase	Same as alteplase	STAT	STAT	-	STAT
Blood pressure management (pre-thrombolysis) - Labetalol	IV	-	10-20 mg :: IV :: - :: 10-20 mg IV over 1-2 min; may repeat or double q10min; max 300 mg	Asthma, severe bradycardia, decompensated HF, 2nd/3rd degree heart block	Continuous BP; target BP <185/110 for tPA eligibility	STAT	STAT	-	STAT
Blood pressure management (pre-thrombolysis) - Nicardipine	IV	-	5 mg/hr :: IV :: - :: Start 5 mg/hr IV; increase by 2.5 mg/hr q5-15min; max 15 mg/hr	None significant	Continuous BP; target <185/110	STAT	STAT	-	STAT
Blood pressure management (pre-thrombolysis) - Clevidipine	IV	-	1-2 mg/hr :: IV :: - :: Start 1-2 mg/hr IV; titrate by doubling q90sec initially; max 32 mg/hr	Soy/egg allergy, severe aortic stenosis, lipid disorders	Continuous BP; rapid onset; short half-life	STAT	STAT	-	STAT
Blood pressure management (post-tPA)	-	-	Same agents as above	Same	Maintain BP <180/105 for 24 hours post-tPA	STAT	STAT	-	STAT
Mechanical thrombectomy	-	-	Endovascular clot retrieval; within 6 hours for anterior LVO; up to 24 hours with favorable perfusion imaging	Large completed infarct (ASPECTS <6), poor baseline function (mRS >2), no LVO	Post-procedure: BP per protocol, groin site checks, neuro checks q1h	STAT	STAT	-	STAT

3B. Acute Supportive Care¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
NPO status	-	All acute stroke until swallow evaluation	NPO until formal swallow screen passed	None	Aspiration risk	STAT	STAT	-	STAT
IV fluids (isotonic) - Normal saline	IV	Volume resuscitation; avoid hypotension	0.9% :: - :: - :: 0.9% NaCl; avoid dextrose-containing fluids (hyperglycemia worsens outcomes)	Volume overload	I/O, daily weights	STAT	STAT	-	STAT
Glucose management - Insulin	IV	Hyperglycemia in acute stroke	140-180 mg :: IV :: - :: Sliding scale or infusion; target glucose 140-180 mg/dL	Avoid hypoglycemia (<60)	Glucose q1-6h depending on regimen	STAT	STAT	-	STAT
DVT prophylaxis - Intermittent pneumatic compression	-	All immobile patients	Apply to both legs	Active DVT	Skin checks	STAT	STAT	-	STAT
DVT prophylaxis - Enoxaparin	SC	After 24-48 hours if no hemorrhagic transformation and not on anticoagulation	40 mg :: SC :: daily :: 40 mg SC daily; reduce to 30 mg if CrCl <30	Active bleeding, HIT, hemorrhagic transformation	Platelets; signs of bleeding	-	ROUTINE	-	ROUTINE
DVT prophylaxis - Heparin (unfractionated)	SC	Alternative to enoxaparin if CrCl <30	5000 units :: SC :: - :: 5000 units SC q8-12h	Same as enoxaparin	Same	-	ROUTINE	-	ROUTINE
Fever management - Acetaminophen	PO	Target normothermia; fever worsens outcomes	650-1000 mg :: PO :: PRN :: 650-1000 mg PO/PR q4-6h PRN temp >38C; max 4g/day	Hepatic impairment	Temperature	STAT	STAT	-	STAT
Head of bed positioning	-	Optimize perfusion vs aspiration risk	HOB flat to 15 degrees initially if no LVO treated; elevate to 30 degrees if large infarct or aspiration risk	None	Neuro exam	STAT	STAT	-	STAT
Supplemental oxygen	-	Hypoxia	94% :: - :: - :: Titrate to SpO2 >94%; avoid routine oxygen in non-hypoxic patients	None	Continuous SpO2	STAT	STAT	-	STAT

3C. Secondary Prevention (Initiate During Hospitalization)¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Aspirin	PO	Non-cardioembolic stroke; first-line antiplatelet	325 mg :: PO :: daily :: Loading: 325 mg (after tPA, wait 24h and confirm no ICH on CT); Maintenance: 81-325 mg daily	Active bleeding, aspirin allergy, concurrent anticoagulation	Bleeding signs	-	ROUTINE	ROUTINE	-
Clopidogrel	PO	Aspirin intolerance; or DAPT (see below)	300-600 mg :: PO :: daily :: Loading: 300-600 mg; Maintenance: 75 mg daily	Active bleeding, severe hepatic impairment	Bleeding, bruising	-	ROUTINE	ROUTINE	-
Dual antiplatelet therapy (DAPT) - Aspirin + Clopidogrel	-	Minor stroke (NIHSS ≤3) or high-risk TIA within 24 hours; continue 21 days then single agent	81 mg :: PO :: daily :: Aspirin 81 mg + Clopidogrel 75 mg daily x 21 days; preceded by loading doses	Major stroke, high bleeding risk, planned surgery	Bleeding; discontinue one agent at day 21	-	ROUTINE	ROUTINE	-
Dual antiplatelet therapy (DAPT) - Aspirin + Ticagrelor	-	Alternative DAPT regimen (THALES trial)	81 mg :: PO :: BID :: Aspirin 81 mg + Ticagrelor 90 mg BID x 30 days	Same as above; avoid with strong CYP3A4 inhibitors	Same; dyspnea (common)	-	ROUTINE	ROUTINE	-
Atorvastatin	PO	All ischemic stroke; high-intensity statin	40-80 mg :: PO :: daily :: 40-80 mg daily; start in hospital	Active liver disease, pregnancy	LFTs at baseline; CK if myalgia	-	ROUTINE	ROUTINE	-
Rosuvastatin	PO	Alternative high-intensity statin	20-40 mg :: PO :: daily :: 20-40 mg daily	Same as atorvastatin; dose adjust for Asian patients, CKD	Same	-	ROUTINE	ROUTINE	-
Apixaban	PO	Cardioembolic stroke (AF); start after imaging confirms no hemorrhagic transformation	5 mg :: PO :: BID :: 5 mg BID; reduce to 2.5 mg BID if 2 of: age ≥80, weight ≤60 kg, Cr ≥1.5	Active bleeding, mechanical valve, severe hepatic impairment; delay 4-14 days post-stroke based on infarct size	Renal function; bleeding	-	ROUTINE	ROUTINE	-
Rivaroxaban	PO	Alternative DOAC for AF	20 mg :: PO :: daily :: 20 mg daily with dinner; 15 mg if CrCl 15-50	Same as apixaban	Same	-	ROUTINE	ROUTINE	-
Dabigatran	PO	Alternative DOAC for AF	150 mg :: PO :: BID :: 150 mg BID; 75 mg BID if CrCl 15-30	Same as apixaban; GI upset common	Same; requires reversal agent availability	-	ROUTINE	ROUTINE	-
Edoxaban	PO	Alternative DOAC for AF	60 mg :: PO :: daily :: 60 mg daily; 30 mg if CrCl 15-50, weight ≤60 kg, or concurrent P-gp inhibitor	Same as apixaban	Same	-	ROUTINE	ROUTINE	-
Warfarin	-	Mechanical valve, antiphospholipid syndrome, DOAC contraindication	Start with DOAC or heparin bridge; target INR 2-3 (2.5-3.5 for mechanical mitral)	Same as DOACs	INR weekly then monthly	-	ROUTINE	ROUTINE	-
Lisinopril	PO	Hypertension; target BP <130/80 after acute phase	2.5-5 mg :: PO :: daily :: Start 2.5-5 mg daily; titrate to 20-40 mg daily	Bilateral renal artery stenosis, angioedema history, pregnancy	BP, K+, Cr	-	ROUTINE	ROUTINE	-
Amlodipine	PO	Hypertension; add-on or alternative	5 mg :: PO :: daily :: Start 5 mg daily; max 10 mg daily	Severe aortic stenosis	BP, peripheral edema	-	ROUTINE	ROUTINE	-
Chlorthalidone	PO	Hypertension; add-on for volume-dependent HTN	12.5-25 mg :: PO :: daily :: 12.5-25 mg daily	Sulfa allergy (relative), hypokalemia, gout	K+, Na+, uric acid	-	ROUTINE	ROUTINE	-

3D. Complications Management¶

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Mannitol	IV	Cerebral edema; increased ICP	0.5-1.5 g/kg :: IV :: q6h :: 0.5-1.5 g/kg IV over 20-30 min; may repeat q6h; serum osm goal <320	-	Hypovolemia, anuria	Serum osm, Na+, renal function; Foley required	-	URGENT	-	STAT
Hypertonic saline 23.4%	IV	Severe cerebral edema; herniation	30 mL :: IV :: - :: 30 mL IV push via central line over 10-20 min	-	Severe hypernatremia (Na >160)	Na q4-6h; target Na 145-155 for edema	-	URGENT	-	STAT
Hypertonic saline 3%	IV	Cerebral edema (less severe)	150-500 mL :: IV :: continuous :: 150-500 mL IV bolus or continuous infusion at 30-50 mL/hr	-	Same	Same	-	URGENT	-	STAT
Decompressive craniectomy	-	Malignant MCA infarction with edema; age <60	Surgical; within 48 hours of stroke onset	-	Poor pre-stroke function, extensive infarct, patient/family preference	Post-op neuro checks, ICP if monitored	-	URGENT	-	URGENT
Levetiracetam	IV	Seizure prophylaxis not routinely recommended; use only if seizure occurs	500-1000 mg :: IV :: BID :: 500-1000 mg IV/PO BID; max 3000 mg/day	-	None significant	Mood, behavior	-	ROUTINE	ROUTINE	ROUTINE
Ceftriaxone + Metronidazole	IV	Aspiration pneumonia	1-2 g :: IV :: q8h :: Ceftriaxone 1-2 g IV daily + Metronidazole 500 mg IV/PO q8h	-	Cephalosporin allergy, alcohol with metronidazole	WBC, fever, respiratory status	-	ROUTINE	-	ROUTINE

3E. Special Situations¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Heparin infusion	-	Cervical artery dissection (controversial), bridge to warfarin	80 units/kg :: - :: once :: 80 units/kg bolus, then 18 units/kg/hr; titrate to PTT 60-80	Active bleeding, large infarct, hemorrhagic transformation	PTT q6h until therapeutic, then q12-24h	-	ROUTINE	-	ROUTINE
PFO closure (device)	-	Cryptogenic stroke with high-risk PFO (large shunt, atrial septal aneurysm); age <60	Interventional procedure; typically after stroke recovery	Active infection, other stroke etiology identified	Post-procedure: antiplatelet therapy, bubble study follow-up	-	-	ROUTINE	-
Carotid endarterectomy (CEA)	-	Symptomatic carotid stenosis 70-99%; some benefit 50-69%	Surgical; timing 2-14 days post-stroke optimal	Unstable medical condition, near-complete occlusion	Post-op: BP control, neuro checks	-	ROUTINE	ROUTINE	-
Carotid artery stenting (CAS)	-	Alternative to CEA; high surgical risk patients	Interventional procedure	Same contraindications as surgery; unfavorable anatomy	Post-procedure: DAPT x 30 days minimum	-	ROUTINE	ROUTINE	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	Indication	ED	HOSP	OPD	ICU
Stroke neurology consult	All acute ischemic stroke	STAT	STAT	ROUTINE	STAT
Interventional neuroradiology/neuroendovascular	LVO identified; thrombectomy candidate	STAT	STAT	-	STAT
Neurosurgery consult	Malignant edema; decompressive craniectomy candidate	URGENT	URGENT	-	STAT
Cardiology consult	AF management, PFO evaluation, cardiac source workup	-	ROUTINE	ROUTINE	ROUTINE
Vascular surgery consult	Symptomatic carotid stenosis; CEA candidate	-	ROUTINE	ROUTINE	-
Speech-language pathology	Swallow evaluation; aphasia therapy	-	STAT	ROUTINE	ROUTINE
Physical therapy	Mobility, gait, balance	-	ROUTINE	ROUTINE	ROUTINE
Occupational therapy	ADLs, upper extremity function	-	ROUTINE	ROUTINE	ROUTINE
Rehabilitation medicine (PM&R)	Inpatient rehabilitation placement	-	ROUTINE	ROUTINE	-
Social work	Discharge planning, community resources	-	ROUTINE	ROUTINE	-
Case management	Insurance authorization, rehab placement	-	ROUTINE	ROUTINE	-
Palliative care	Large stroke with poor prognosis; goals of care	-	ROUTINE	-	ROUTINE
Smoking cessation counseling	All smokers	-	ROUTINE	ROUTINE	-
Nutrition/Dietitian	Dysphagia diet, heart-healthy diet education	-	ROUTINE	ROUTINE	-

4B. Patient Instructions¶

Recommendation	ED	HOSP	OPD
Call 911 immediately if new or worsening weakness, numbness, vision changes, speech difficulty, or severe headache	✓	✓	✓
Know stroke warning signs: F.A.S.T. (Face drooping, Arm weakness, Speech difficulty, Time to call 911)	✓	✓	✓
Take all prescribed medications as directed; do not stop antiplatelet or anticoagulant without physician guidance	✓	✓	✓
Attend all follow-up appointments (neurology, cardiology, primary care)	-	✓	✓
No driving until cleared by physician (typically minimum 2-4 weeks; varies by state law and deficit severity)	✓	✓	✓
Report any bleeding (blood in stool, urine, gums, excessive bruising) while on blood thinners	-	✓	✓
Check blood pressure at home daily if hypertensive; keep log for follow-up visits	-	✓	✓
Monitor blood glucose if diabetic; maintain good glycemic control	-	✓	✓
Follow swallow precautions if dysphagia present (diet modification, positioning, supervision)	-	✓	✓
Use fall precautions: clear pathways, use assistive devices as prescribed, adequate lighting	-	✓	✓

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Smoking cessation (most important modifiable risk factor)	✓	✓	✓
Blood pressure control: target <130/80 mmHg	-	✓	✓
LDL cholesterol target <70 mg/dL (or 50% reduction) with high-intensity statin	-	✓	✓
Diabetes management: HbA1c target <7%	-	✓	✓
Limit alcohol: ≤1 drink/day women, ≤2 drinks/day men; abstinence if alcohol-related stroke	✓	✓	✓
Heart-healthy diet: Mediterranean or DASH diet	-	✓	✓
Regular aerobic exercise: 40 min moderate-intensity 3-4 days/week when able	-	✓	✓
Weight management: BMI target 18.5-24.9	-	✓	✓
Sleep apnea screening and treatment if indicated	-	✓	✓
Avoid illicit drugs (cocaine, amphetamines)	✓	✓	✓
Hormone replacement therapy: avoid or use caution	-	✓	✓
Stress management	-	-	✓

SECTION B: REFERENCE (Expand as Needed)¶

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Hypoglycemia	Rapid response to glucose; often diabetic on insulin/sulfonylureas	Point-of-care glucose; resolves with correction
Seizure with Todd's paralysis	History of seizure; gradual resolution over hours; post-ictal confusion	EEG; witnessed seizure; gradual resolution
Complex migraine with aura	Headache (usually); positive symptoms (scintillating scotoma); history of similar; <60 min	Clinical history; normal imaging; resolves
Intracranial hemorrhage	Sudden severe headache; rapid progression; may have anticoagulation history	CT head shows hemorrhage
Brain tumor	Gradual onset; headache; seizures; may have mass effect	MRI brain shows mass lesion
Subdural hematoma	History of trauma (may be minor); elderly; anticoagulation	CT shows crescent-shaped collection
Encephalitis	Fever; altered mental status; seizures; behavioral changes	MRI (temporal lobe); LP; CSF PCR
Multiple sclerosis (acute relapse)	Younger patient; prior episodes; MRI pattern (periventricular, Dawson fingers)	MRI brain/spine; LP (oligoclonal bands)
Conversion disorder/functional neurological disorder	Inconsistent exam; positive functional signs (Hoover, give-way weakness)	Clinical; normal imaging; psychiatric history
Wernicke encephalopathy	Ataxia, ophthalmoplegia, confusion; alcohol/malnutrition history	Clinical; MRI (mammillary bodies); thiamine response
Hypertensive encephalopathy	Severely elevated BP; headache; confusion; PRES pattern on MRI	MRI (PRES); BP reduction reverses symptoms
Cerebral venous sinus thrombosis	Headache; may have hypercoagulable state or OCP use; hemorrhagic infarcts	CT/MR venography; D-dimer
Hyponatremia	Confusion, seizures; recent medication change; SIADH	BMP shows low sodium
Hepatic encephalopathy	Liver disease; asterixis; confusion	Ammonia; LFTs; history
Drug intoxication	History of substance use; pupils; toxidrome	Urine drug screen

6. MONITORING PARAMETERS¶

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
NIHSS (National Institutes of Health Stroke Scale)	Q1h x 24h, then q4h x 48h, then q shift	Stable or improving	If worsening ≥4 points: emergent CT, consider hemorrhage or extension	STAT	STAT	ROUTINE	STAT
Blood pressure	Q15min x 2h post-tPA, then q30min x 6h, then q1h x 16h; q4h after	<180/105 post-tPA x 24h; then individualize (avoid hypotension acutely)	Treat per protocol; labetalol, nicardipine	STAT	STAT	ROUTINE	STAT
Glucose	Q6h; q1h if on insulin infusion	140-180 mg/dL (avoid <60 and >180)	Insulin adjustment	STAT	STAT	ROUTINE	STAT
Temperature	Q4h	<38°C	Acetaminophen; cooling; infection workup if fever	STAT	ROUTINE	-	STAT
Oxygen saturation	Continuous if on supplemental O2	>94%	Oxygen titration; evaluate for aspiration, PE	STAT	STAT	-	STAT
Neurological examination	Q1h x 24h, then per protocol	Stable or improving	If worsening: emergent imaging	STAT	STAT	ROUTINE	STAT
INR (if on warfarin)	Daily until therapeutic	2-3 (or 2.5-3.5 for mechanical mitral)	Warfarin dose adjustment	-	ROUTINE	ROUTINE	ROUTINE
Renal function (Cr, BUN)	Daily during hospitalization; baseline for DOACs	Stable	DOAC dose adjustment; avoid nephrotoxins	-	ROUTINE	ROUTINE	ROUTINE
Lipid panel	Fasting, within 24-48h	LDL <70	Statin intensification	-	ROUTINE	ROUTINE	-
HbA1c	Once during hospitalization	<7%	Diabetes medication optimization	-	ROUTINE	ROUTINE	-
Swallow evaluation	Before any oral intake	Pass bedside or instrumental swallow	NPO; modified diet; SLP consult	-	STAT	-	STAT
Continuous cardiac telemetry	Minimum 24-72 hours	Identify AF, arrhythmias	Anticoagulation if AF detected	STAT	STAT	-	STAT
Repeat CT head	24 hours post-tPA; or if neurological decline	No hemorrhagic transformation	If hemorrhage: reverse anticoagulation, neurosurgery consult	-	ROUTINE	-	ROUTINE

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge home	Minor stroke or TIA; able to ambulate safely or with minimal assistance; swallow intact; stable on oral medications; adequate home support; follow-up arranged within 1-2 weeks; compliant with secondary prevention
Admit to stroke unit/floor	Most acute ischemic strokes; requires monitoring, workup, rehabilitation assessment; stable vital signs; no respiratory compromise
Admit to ICU	Received tPA or thrombectomy (24h monitoring); large vessel occlusion; declining neurological exam; respiratory compromise; malignant edema risk; BP requiring IV infusion; arrhythmia requiring intervention
Inpatient rehabilitation	Significant functional deficits; able to participate in 3 hours therapy/day; medically stable; expected to benefit
Skilled nursing facility	Functional deficits; unable to tolerate intensive rehabilitation; needs skilled nursing care
Long-term acute care (LTAC)	Prolonged ventilator dependence; complex medical needs
Transfer to comprehensive stroke center	LVO needing thrombectomy not available locally; neurosurgical intervention needed; complex case

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
IV alteplase within 4.5 hours improves outcomes	Class I, Level A	NINDS, ECASS III
Tenecteplase non-inferior to alteplase	Class I, Level B	AcT Trial, Campbell et al. NEJM 2022
Mechanical thrombectomy for LVO within 6 hours	Class I, Level A	MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT
Thrombectomy up to 24 hours with favorable imaging	Class I, Level A	DAWN; DEFUSE 3
DAPT (aspirin + clopidogrel) for minor stroke/high-risk TIA x 21 days	Class I, Level A	CHANCE; POINT
High-intensity statin therapy	Class I, Level A	SPARCL; AHA/ASA Guidelines
Anticoagulation for AF-related stroke	Class I, Level A	AHA/ASA Guidelines 2021
Blood pressure management post-stroke	Class I, Level B	AHA/ASA Guidelines 2021
Early mobilization	Class III (Harm), Level A	AVERT Trial - very early mobilization harmful
Decompressive craniectomy for malignant MCA stroke	Class I, Level A	DECIMAL, DESTINY, HAMLET
PFO closure for cryptogenic stroke	Class I, Level B	CLOSE; RESPECT; DEFENSE-PFO
Carotid endarterectomy for symptomatic stenosis ≥70%	Class I, Level A	NASCET; ECST
Intensive glucose control (avoid hypoglycemia)	Class I, Level C	AHA/ASA Guidelines
Fever treatment	Class I, Level C	AHA/ASA Guidelines

CHANGE LOG¶

v1.0 (January 21, 2026) - Initial template creation - Comprehensive hyperacute, acute, and secondary prevention protocols - Includes tPA/tenecteplase, thrombectomy decision-making - Etiologic workup for cryptogenic and young stroke - Cardioembolic stroke management with DOAC guidance - Malignant edema and complications management - Full disposition criteria for all levels of care

APPENDIX A: tPA Exclusion Criteria¶

Absolute Contraindications (Standard 0-3 Hour Window)¶

Contraindication	Details
Intracranial hemorrhage	Any history or evidence on imaging
Subarachnoid hemorrhage	Clinical or imaging evidence
Recent intracranial/spinal surgery	Within 3 months
Recent serious head trauma	Within 3 months
Intracranial neoplasm	Excluding meningiomas
Arteriovenous malformation or aneurysm	If known
Active internal bleeding	Excluding menses
Bleeding diathesis	Platelets <100K, INR >1.7, PTT elevation, current anticoagulation with therapeutic levels
Blood pressure >185/110 mmHg	Despite antihypertensive treatment
Blood glucose <50 mg/dL	Hypoglycemia must be corrected first

Relative Contraindications (Require Risk-Benefit Assessment)¶

Contraindication	Considerations
Minor or rapidly improving symptoms	May proceed if still disabling
Pregnancy	Consider if large vessel stroke with disabling deficits
Major surgery within 14 days	Assess surgical site bleeding risk
GI or urinary tract hemorrhage within 21 days	Risk assessment
Recent myocardial infarction	Within 3 months; consult cardiology
Seizure at onset with postictal residual	If true stroke suspected, may proceed
Arterial puncture at non-compressible site within 7 days	Risk assessment
Prior ischemic stroke within 3 months	Extended window (3-4.5 hours) relative

Extended Window (3-4.5 Hours) Additional Relative Contraindications¶

Contraindication	Details
Age >80 years	Now considered relative (may benefit)
NIHSS >25	Very severe stroke
Oral anticoagulant use	Regardless of INR
History of both diabetes AND prior stroke	Historical exclusion; now relative

APPENDIX B: NIHSS Quick Reference¶

Score	Severity	General Outcome
0	No stroke symptoms	May still have significant deficits
1-4	Minor stroke	Often good outcome; DAPT candidate if ≤3
5-15	Moderate stroke	Variable outcomes
16-20	Moderate-severe stroke	Often requires intensive rehabilitation
21-42	Severe stroke	High mortality and disability risk