Acute Ischemic Stroke¶

VERSION: 1.0 CREATED: January 27, 2026 STATUS: Initial build

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)

SYNONYMS: Acute ischemic stroke, AIS, stroke, brain attack, cerebral infarction, CVA, cerebrovascular accident, thrombotic stroke, embolic stroke, ischemic CVA, ischemic stroke, code stroke

SCOPE: Acute ischemic stroke in adults — covers initial stabilization, thrombolytic therapy (IV alteplase/tenecteplase), endovascular thrombectomy criteria, blood pressure management, stroke etiology workup, secondary prevention initiation, and early rehabilitation. Excludes hemorrhagic stroke (see Intracerebral Hemorrhage template), transient ischemic attack (see TIA template), pediatric stroke, and chronic post-stroke management.

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	ED	HOSP	OPD	ICU	Rationale	Target Finding
Point-of-care glucose (CPT 82962)	STAT	STAT	-	STAT	Hypoglycemia mimics stroke; must rule out before tPA	>60 mg/dL
CBC with differential (CPT 85025)	STAT	STAT	ROUTINE	STAT	Baseline; thrombocytopenia contraindicates tPA if <100K	Platelets >100,000
BMP (Na, K, Cr, glucose, BUN) (CPT 80048)	STAT	STAT	ROUTINE	STAT	Electrolyte abnormalities, renal function for contrast/medication dosing	Normal
PT/INR (CPT 85610)	STAT	STAT	-	STAT	Anticoagulant use; INR >1.7 contraindicates tPA	INR ≤1.7 for tPA eligibility
aPTT (CPT 85730)	STAT	STAT	-	STAT	Heparin use; elevated aPTT contraindicates tPA	Normal range
Troponin (CPT 84484)	STAT	STAT	-	STAT	Acute MI can cause cardioembolic stroke; stress cardiomyopathy	Normal
Type and screen (CPT 86900)	STAT	ROUTINE	-	STAT	Potential need for blood products, surgical intervention	On file
Lipid panel (fasting or non-fasting) (CPT 80061)	-	ROUTINE	ROUTINE	-	Baseline for statin therapy; cardiovascular risk assessment	LDL target <70 mg/dL
HbA1c (CPT 83036)	-	ROUTINE	ROUTINE	-	Diabetes screening/management; cardiovascular risk factor	<7.0% (individualized)

1B. Extended Workup (Second-line)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Hepatic function panel (AST, ALT, albumin) (CPT 80076)	URGENT	ROUTINE	ROUTINE	URGENT	Liver disease affects anticoagulation, medication metabolism	Normal
TSH (CPT 84443)	-	ROUTINE	ROUTINE	-	Thyroid dysfunction as cardiovascular risk factor; atrial fibrillation workup	Normal
ESR (CPT 85652) / CRP (CPT 86140)	-	ROUTINE	ROUTINE	-	Vasculitis screen, inflammatory stroke etiology	Normal
Urine drug screen (CPT 80307)	URGENT	ROUTINE	-	URGENT	Cocaine/amphetamine-associated vasospasm or stroke	Negative
Pregnancy test (β-hCG) (CPT 84703)	STAT	STAT	ROUTINE	STAT	Affects treatment decisions (tPA risk-benefit), imaging choices	Negative
Blood alcohol level (CPT 80320)	URGENT	-	-	URGENT	Intoxication as stroke mimic; affects exam reliability	Correlate with clinical picture
Magnesium (CPT 83735)	URGENT	ROUTINE	ROUTINE	URGENT	Hypomagnesemia associated with arrhythmia, vascular risk	Normal (>1.8 mg/dL)
Phosphorus (CPT 84100)	-	ROUTINE	ROUTINE	-	Refeeding risk if malnourished; metabolic panel	Normal
Prealbumin	-	ROUTINE	-	ROUTINE	Nutritional status for rehabilitation planning	Normal

1C. Rare/Specialized (Refractory or Atypical)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Hypercoagulable panel (protein C, protein S, antithrombin III, Factor V Leiden, prothrombin gene mutation)	-	EXT	EXT	-	Young stroke (<50), cryptogenic stroke, venous thrombosis history	Normal
Antiphospholipid antibody panel (lupus anticoagulant, anticardiolipin, β2-glycoprotein I)	-	EXT	EXT	-	Young stroke, recurrent stroke, systemic lupus	Negative
Homocysteine (CPT 83090)	-	ROUTINE	ROUTINE	-	Elevated homocysteine as independent stroke risk factor	Normal (<15 µmol/L)
RPR/VDRL (CPT 86592)	-	ROUTINE	ROUTINE	-	Syphilitic vasculitis	Negative
HIV (CPT 87389)	-	ROUTINE	ROUTINE	-	HIV-associated vasculopathy	Negative
ANA (CPT 86235), dsDNA	-	EXT	EXT	-	Lupus cerebritis, vasculitis	Negative
ANCA (c-ANCA, p-ANCA)	-	EXT	EXT	-	CNS vasculitis	Negative
Complement levels (C3, C4)	-	EXT	EXT	-	Complement-mediated vasculitis	Normal
Hemoglobin electrophoresis	-	EXT	EXT	-	Sickle cell disease (young patients, African descent)	Normal (HbAA)
JAK2 mutation	-	EXT	EXT	-	Polycythemia vera, myeloproliferative disorders	Negative
Fibrinogen (CPT 85384)	URGENT	ROUTINE	-	URGENT	DIC screen, coagulopathy evaluation	Normal (200-400 mg/dL)
D-dimer (CPT 85379)	URGENT	ROUTINE	-	URGENT	DIC, paradoxical embolism through PFO, cancer-associated	Normal

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
CT head without contrast (CPT 70450)	STAT	STAT	-	STAT	Door-to-CT <25 minutes	Exclude hemorrhage; may show early ischemic changes (loss of gray-white differentiation, sulcal effacement)	Pregnancy (relative)
CT angiography head and neck (CTA) (CPT 70496, 70498)	STAT	STAT	-	STAT	With initial CT; door-to-CTA <25 min	Large vessel occlusion (LVO) for thrombectomy; carotid/vertebral stenosis or dissection	Contrast allergy (premedicate), eGFR <30 (benefit outweighs risk in acute setting)
CT perfusion (CTP) (CPT 0042T)	STAT	URGENT	-	STAT	With CTA if extended window (6-24h) or wake-up stroke	Ischemic penumbra (mismatch between core infarct and hypoperfused tissue); target mismatch ratio >1.8	Same as CTA
MRI brain with DWI (diffusion-weighted imaging) (CPT 70553)	URGENT	URGENT	ROUTINE	URGENT	Within 24h; STAT if diagnosis uncertain	Acute ischemic infarct (restricted diffusion); stroke location and extent; ASPECTS scoring	Pacemaker, metallic implants, severe claustrophobia
ECG (12-lead) (CPT 93000)	STAT	STAT	ROUTINE	STAT	Immediate	Atrial fibrillation, acute MI, LVH, ST changes	None

2B. Extended¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRA head and neck (CPT 70544, 70547)	-	URGENT	ROUTINE	URGENT	Within 24-48h	Intracranial stenosis, vertebrobasilar disease, dissection	Same as MRI
Transthoracic echocardiogram (TTE) (CPT 93306)	-	ROUTINE	ROUTINE	ROUTINE	Within 24-48h	LV thrombus, PFO, valvular disease, cardiomyopathy, akinetic segments	None significant
Transesophageal echocardiogram (TEE) (CPT 93312) with bubble study	-	ROUTINE	ROUTINE	-	Within 48-72h if TTE nondiagnostic or cryptogenic stroke	PFO with right-to-left shunt, atrial septal aneurysm, left atrial appendage thrombus, aortic arch atheroma	Esophageal pathology, uncooperative patient
Carotid duplex ultrasound (CPT 93880)	-	ROUTINE	ROUTINE	-	Within 24-48h	Carotid stenosis ≥50%, plaque characterization	None significant
Transcranial Doppler (TCD) (CPT 93886)	-	ROUTINE	ROUTINE	-	Within 24-48h	Intracranial stenosis, vasospasm, microembolic signals, right-to-left shunt (bubble study)	Absent temporal bone window (~10% patients)
Continuous cardiac telemetry (CPT 93228)	STAT	STAT	-	STAT	Minimum 24h; ideally ≥48-72h	Paroxysmal atrial fibrillation, other arrhythmias	None
Extended cardiac monitoring (Holter 30-day or implantable loop recorder)	-	ROUTINE	ROUTINE	-	Arrange before discharge if cryptogenic stroke	Paroxysmal atrial fibrillation (detected in 12-30% with prolonged monitoring)	None significant
Chest X-ray (CPT 71046)	URGENT	ROUTINE	-	URGENT	Within 24h	Cardiomegaly, pulmonary edema, aspiration pneumonia	None significant

2C. Rare/Specialized¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Conventional cerebral angiography (DSA) (CPT 36224)	-	EXT	EXT	EXT	If vasculitis, dissection, or Moyamoya suspected	Beading pattern (vasculitis), intimal flap (dissection), Moyamoya collaterals	Contrast allergy, severe renal impairment, coagulopathy
MRI vessel wall imaging	-	EXT	EXT	-	If intracranial stenosis or vasculitis suspected	Vessel wall enhancement (vasculitis, unstable plaque), dissection	Same as MRI
Fat-saturated MRI neck	-	EXT	EXT	-	If cervical dissection suspected	Intramural hematoma (crescent sign)	Same as MRI
Cardiac MRI	-	EXT	EXT	-	If cardiomyopathy or cardiac mass suspected	Myocardial fibrosis, thrombus, tumor	Same as MRI
PET-CT	-	-	EXT	-	If occult malignancy suspected (Trousseau syndrome)	Occult cancer, hypercoagulable etiology	Pregnancy, uncontrolled diabetes

3. TREATMENT¶

3A. Acute/Emergent¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
IV alteplase (tPA) (CPT 96365)	IV	-	0.9 mg/kg :: IV :: once :: 0.9 mg/kg IV (max 90 mg); 10% as bolus over 1 min, remaining 90% infused over 60 min. Door-to-needle target <45 min	>4.5h from last known well (relative 3-4.5h window with additional exclusions); BP >185/110 despite treatment; platelets <100K; INR >1.7; active bleeding; recent surgery <14 days; recent stroke <3 months; intracranial hemorrhage history	Neuro checks q15min during infusion, q30min x 6h, then q1h x 18h; BP q15min x 2h, q30min x 6h, then q1h; hold anticoagulants/antiplatelets 24h	STAT	STAT	-	STAT
Tenecteplase IV (CPT 96374) (if available)	IV	-	0.25 mg/kg :: IV :: once :: 0.25 mg/kg IV single bolus (max 25 mg); preferred if LVO planned for thrombectomy	Same as alteplase	Same as alteplase	STAT	STAT	-	STAT
Endovascular thrombectomy	-	-	N/A :: - :: once :: For LVO (ICA, M1, M1-M2 junction, basilar); within 24h if eligible per DAWN/DEFUSE-3 criteria. 0-6h: NIHSS ≥6, ASPECTS ≥6. 6-24h: clinical-core mismatch on perfusion imaging	Large established infarct core (ASPECTS <6 in 0-6h window); no LVO; poor premorbid function (mRS >2 relative); life expectancy <6 months	Continuous monitoring in neuro-ICU post-procedure; groin check; BP per post-thrombectomy protocol	STAT	STAT	-	STAT
Aspirin	PO	-	325 mg :: PO :: daily :: 325 mg PO/PR load (give within 24-48h of onset); if tPA given, wait 24h and obtain CT before starting. Maintenance: 81-325 mg daily	Active GI bleed, true aspirin allergy, within 24h of tPA (wait for post-tPA CT)	GI symptoms, bleeding signs	STAT	STAT	-	STAT
Blood pressure management PRE-tPA: Labetalol IV (CPT 96374)	IV	-	10-20 mg :: IV :: once :: 10-20 mg IV over 1-2 min; may repeat once; target BP <185/110 before tPA	Heart block (2nd/3rd degree), severe bradycardia, decompensated HF, asthma/severe COPD	Heart rate, BP continuous	STAT	STAT	-	STAT
Blood pressure management PRE-tPA: Nicardipine IV (CPT 96365)	IV	-	5 mg/h :: IV :: - :: 5 mg/h IV infusion; increase by 2.5 mg/h q5-15min; max 15 mg/h; target BP <185/110	Severe aortic stenosis	BP continuous monitoring	STAT	STAT	-	STAT
Blood pressure management PRE-tPA: Clevidipine IV (CPT 96365)	IV	-	1-2 mg/h :: IV :: - :: 1-2 mg/h IV; titrate by doubling q90sec initially; max 32 mg/h	Soy/egg allergy, severe lipid disorders, defective lipid metabolism	BP continuous monitoring	STAT	STAT	-	STAT
Blood pressure management POST-tPA (24h)	IV	-	N/A :: IV :: continuous :: Target BP <180/105 x 24h post-tPA; use nicardipine or labetalol drip as above	See individual agents above	Neuro checks with each BP check; hold if SBP <100	-	STAT	-	STAT
Permissive hypertension (no tPA given)	-	-	15% :: - :: - :: Allow BP up to 220/120; treat only if >220/120 or end-organ damage (ACS, aortic dissection, hypertensive encephalopathy). Lower by 15% in first 24h	N/A	Neuro checks; avoid precipitous drops	STAT	STAT	-	STAT
IV normal saline	IV	-	N/A :: IV :: per protocol :: Isotonic fluids; avoid dextrose-containing solutions (hyperglycemia worsens outcomes); avoid hypotonic solutions (cerebral edema risk)	Volume overload	I/O, electrolytes	STAT	STAT	-	STAT
Supplemental oxygen	-	-	94% :: - :: - :: Only if SpO2 <94%; nasal cannula or mask as needed	N/A	SpO2 target ≥94%; avoid routine supplemental O2 if normoxic	STAT	STAT	-	STAT

3B. Symptomatic Treatments¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Acetaminophen	PO	Fever (temp >38°C worsens outcomes)	650-1000 mg :: PO :: q6h :: 650-1000 mg PO/PR q6h; max 4g/day (2g if hepatic impairment)	Severe hepatic disease	Temperature q4h; LFTs if prolonged use	STAT	STAT	-	STAT
Insulin (regular)	IV	Hyperglycemia (glucose >180 worsens outcomes)	140-180 mg :: IV :: - :: Sliding scale or insulin drip for persistent hyperglycemia; target glucose 140-180 mg/dL; avoid hypoglycemia (<60 mg/dL)	Hypoglycemia risk	BG q1h if drip; q6h if sliding scale	STAT	STAT	-	STAT
Ondansetron	IV	Nausea/vomiting (posterior circulation stroke)	4 mg :: IV :: q6h :: 4 mg IV/PO q6h PRN	QT prolongation, serotonin syndrome risk	QTc if risk factors	URGENT	ROUTINE	ROUTINE	URGENT
Enoxaparin	SC	DVT prophylaxis	40 mg :: SC :: daily :: 40 mg SC daily; start within 24-48h if not receiving therapeutic anticoagulation; after post-tPA imaging clears hemorrhage	Active bleeding, platelets <50K, CrCl <30 (use UFH 5000u SC q8-12h)	Platelets q3 days; renal function	-	ROUTINE	-	ROUTINE
Heparin (unfractionated) SC	SC	DVT prophylaxis (alternative)	5000 units :: SC :: - :: 5000 units SC q8-12h	Active bleeding, HIT	Platelets q3 days	-	ROUTINE	-	ROUTINE
Pneumatic compression devices	-	DVT prophylaxis (non-pharmacologic)	N/A :: - :: continuous :: Apply to both legs immediately on admission; use in addition to or instead of pharmacologic prophylaxis	Acute DVT, severe peripheral vascular disease	Skin checks daily	STAT	STAT	-	STAT
Pantoprazole	IV	GI prophylaxis (stress ulcer)	40 mg :: IV :: daily :: 40 mg IV/PO daily	C. difficile risk with prolonged use	GI symptoms	-	ROUTINE	-	ROUTINE

3C. Second-line/Refractory¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Dual antiplatelet therapy (DAPT): Aspirin + Clopidogrel	-	-	81 mg :: - :: daily :: Aspirin 81 mg + Clopidogrel 75 mg daily x 21 days (minor stroke NIHSS ≤3 or high-risk TIA ABCD2 ≥4); then single antiplatelet long-term. Load clopidogrel 300 mg if not previously on it	Major stroke (NIHSS >3), high bleeding risk, planned surgery	Bleeding signs; CBC	-	URGENT	URGENT	-
Dual antiplatelet therapy: Aspirin + Ticagrelor	PO	-	81 mg :: PO :: daily :: Aspirin 81 mg daily + Ticagrelor 90 mg BID x 30 days (THALES trial: minor stroke NIHSS ≤5); then single antiplatelet	Intracranial stenosis (may use), high bleeding risk, hepatic impairment	Bleeding signs; dyspnea (common side effect)	-	URGENT	URGENT	-
Heparin IV drip (therapeutic)	IV	-	60-80 units/kg :: IV :: once :: Bolus 60-80 units/kg (max 5000u); infusion 12-18 units/kg/h; target aPTT 1.5-2.5x control. Use for: cardiac source with high re-embolization risk, arterial dissection, crescendo TIA, free-floating thrombus	Large infarct (hemorrhagic transformation risk), uncontrolled BP, within 24h of tPA	aPTT q6h until stable, then q12-24h; platelets q3 days; neuro checks	-	URGENT	-	URGENT
Decompressive craniectomy (malignant MCA infarct)	-	-	50% :: - :: - :: For malignant MCA syndrome with >50% MCA territory infarct, age <60 preferred; within 48h of onset; reduces mortality from 70-80% to ~20%	Age >60 (relative — DESTINY II showed benefit up to age 80 but with higher disability); bilateral infarcts; hemorrhagic transformation	Post-operative neuro checks, ICP monitoring, wound care	-	-	-	STAT
Osmotherapy: Mannitol 20%	IV	-	1-1.5 g/kg :: IV :: once :: 1-1.5 g/kg IV bolus for acute herniation; 0.25-0.5 g/kg q4-6h maintenance	Anuria, severe dehydration	Serum osmolality (hold if >320 mOsm/kg), osmolar gap, renal function, I/O	-	-	-	STAT
Osmotherapy: Hypertonic saline 23.4%	IV	-	30 mL :: IV :: once :: 30 mL IV bolus via central line over 10-20 min for acute herniation	No central access for 23.4%; hypokalemia	Serum sodium (target 145-155 mEq/L), osmolality, central line integrity	-	-	-	STAT
Hypertonic saline 3% infusion	IV	-	150-500 mL :: IV :: continuous :: 150-500 mL IV bolus or continuous infusion 0.5-1 mL/kg/h; target Na 145-155	Hypernatremia, volume overload	Serum sodium q4-6h, osmolality	-	-	-	STAT

3D. Disease-Modifying / Chronic Therapies¶

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Atorvastatin	PO	-	80 mg :: PO :: daily :: 80 mg PO daily (high-intensity); start within 24-48h regardless of baseline LDL	-	Active liver disease, pregnancy, breastfeeding	LFTs at 12 weeks then annually; lipid panel at 4-12 weeks; CK if myalgia	-	STAT	ROUTINE	STAT
Rosuvastatin	PO	-	20-40 mg :: PO :: daily :: 20-40 mg PO daily (high-intensity alternative)	-	Active liver disease, pregnancy, CrCl <30 for 40mg	Same as atorvastatin	-	STAT	ROUTINE	STAT
Apixaban	PO	-	5 mg :: PO :: BID :: 5 mg PO BID (2.5 mg BID if ≥2 of: age ≥80, weight ≤60kg, Cr ≥1.5); start 4-14 days post-stroke for AF (timing based on infarct size). Preferred DOAC per guidelines	-	Renal function; bleeding signs; CBC	-	-	ROUTINE	ROUTINE	-
Rivaroxaban	PO	-	20 mg :: PO :: daily :: 20 mg PO daily with evening meal (15 mg daily if CrCl 15-50); start 4-14 days post-stroke for AF	-	Renal function q6-12 months; bleeding signs	-	-	ROUTINE	ROUTINE	-
Dabigatran	PO	-	150 mg :: PO :: BID :: 150 mg PO BID (75 mg BID if CrCl 15-30); start 4-14 days post-stroke for AF	-	Renal function q6-12 months; bleeding signs; GI side effects	-	-	ROUTINE	ROUTINE	-
Warfarin	PO	-	5 mg :: PO :: daily :: 5 mg PO daily initial (2-3 mg if elderly, low weight, or interacting drugs); target INR 2.0-3.0 for AF; 2.5-3.5 for mechanical valve. Bridge with heparin	-	INR daily until stable, then weekly, then monthly; diet counseling (vitamin K)	-	-	ROUTINE	ROUTINE	-
Lisinopril	PO	-	5-10 mg :: PO :: daily :: Start 5-10 mg PO daily; titrate to 20-40 mg daily; target BP <130/80 after acute phase	-	Cr and K+ at 1-2 weeks after initiation; BP	-	-	ROUTINE	ROUTINE	-
Amlodipine	PO	-	5 mg :: PO :: daily :: Start 5 mg PO daily; max 10 mg daily	-	BP, peripheral edema	-	-	ROUTINE	ROUTINE	-
Losartan	PO	-	50 mg :: PO :: daily :: Start 50 mg PO daily; max 100 mg daily	-	Cr, K+, BP	-	-	ROUTINE	ROUTINE	-
Metoprolol succinate	PO	-	25 mg :: PO :: daily :: Start 25 mg PO daily; titrate to 200 mg daily	-	HR, BP	-	-	ROUTINE	ROUTINE	-
Ezetimibe	PO	-	10 mg :: PO :: daily :: 10 mg PO daily; add if LDL not at goal on max statin	-	LFTs, lipid panel	-	-	ROUTINE	ROUTINE	-
PCSK9 inhibitor (evolocumab)	SC	-	140 mg :: SC :: monthly :: 140 mg SC q2 weeks or 420 mg SC monthly; if LDL not at goal on max statin + ezetimibe	-	Lipid panel q4-12 weeks; injection site reactions	-	-	-	ROUTINE	-

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU	Indication
Neurology consultation (stroke team)	STAT	STAT	-	STAT	All acute stroke presentations; tPA decision; stroke workup
Neurointerventional/endovascular consultation	STAT	STAT	-	STAT	Large vessel occlusion on CTA for thrombectomy
Neurosurgery consultation	URGENT	URGENT	-	STAT	Malignant MCA edema, posterior fossa stroke with hydrocephalus, hemorrhagic transformation requiring intervention
Cardiology consultation	-	ROUTINE	ROUTINE	ROUTINE	Newly detected atrial fibrillation, acute MI, cardiomyopathy, PFO evaluation
Vascular surgery consultation	-	ROUTINE	ROUTINE	-	Symptomatic carotid stenosis ≥50% (NASCET) for endarterectomy; ideally within 2 weeks
Speech-language pathology (SLP)	URGENT	STAT	ROUTINE	URGENT	Dysphagia screening before any PO intake; aphasia evaluation; cognitive-communication assessment
Physical therapy (PT)	-	URGENT	ROUTINE	URGENT	Early mobilization within 24-48h (AVERT trial: avoid very early aggressive mobilization <24h); gait and balance training
Occupational therapy (OT)	-	URGENT	ROUTINE	URGENT	ADL assessment, upper extremity function, adaptive equipment, cognitive rehabilitation
Rehabilitation medicine (physiatry)	-	ROUTINE	ROUTINE	-	Determine rehabilitation disposition (inpatient rehab, SNF, home health, outpatient)
Social work	-	ROUTINE	ROUTINE	-	Discharge planning, insurance, DME, caregiver support, advance directives
Nutrition/dietitian	-	ROUTINE	ROUTINE	-	Dysphagia diet recommendations, cardiovascular risk diet (Mediterranean, DASH)
Palliative care	-	ROUTINE	-	ROUTINE	Large territory stroke with poor prognosis, goals of care discussion
Smoking cessation counseling	-	ROUTINE	ROUTINE	-	Active smokers
Case management	-	ROUTINE	ROUTINE	-	Rehabilitation placement, follow-up coordination

4B. Patient Instructions¶

Recommendation	ED	HOSP	OPD
Call 911 immediately if new symptoms: sudden weakness, numbness, vision changes, speech difficulty, severe headache, loss of balance	STAT	STAT	ROUTINE
Do NOT drive until cleared by neurology (minimum 2 weeks; state-specific laws apply)	URGENT	URGENT	ROUTINE
Take all medications as prescribed; do NOT stop antiplatelet or anticoagulant without medical advice	URGENT	URGENT	ROUTINE
Swallowing precautions per SLP recommendations (sit upright 90° for meals, specific diet texture)	URGENT	URGENT	ROUTINE
Fall prevention: clear pathways, use assistive devices, adequate lighting, non-slip surfaces	-	URGENT	ROUTINE
Blood pressure monitoring at home (target <130/80 per physician guidance)	-	ROUTINE	ROUTINE
Stroke signs education for patient and family: F.A.S.T. (Face drooping, Arm weakness, Speech difficulty, Time to call 911)	URGENT	ROUTINE	ROUTINE
Medication list: carry updated list including all prescriptions, OTC, and supplements	-	ROUTINE	ROUTINE
Follow-up appointment with neurology in 1-2 weeks; primary care in 2-4 weeks	-	ROUTINE	ROUTINE
Report any bleeding (bruising, blood in stool/urine, gum bleeding) if on anticoagulation	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Smoking cessation (absolute)	-	ROUTINE	ROUTINE
Blood pressure target <130/80 mmHg	-	ROUTINE	ROUTINE
Mediterranean or DASH diet	-	ROUTINE	ROUTINE
Sodium restriction <2.3 g/day (ideally <1.5 g if hypertensive)	-	ROUTINE	ROUTINE
Regular aerobic exercise: 40 min moderate intensity, 3-4 days/week (after medical clearance)	-	-	ROUTINE
Weight management (BMI 18.5-24.9)	-	ROUTINE	ROUTINE
Alcohol limitation: ≤1 drink/day women, ≤2 drinks/day men; cessation if heavy use	-	ROUTINE	ROUTINE
Glycemic control target HbA1c <7% (individualized)	-	ROUTINE	ROUTINE
LDL target <70 mg/dL (high-intensity statin)	-	ROUTINE	ROUTINE
Obstructive sleep apnea screening (Berlin questionnaire or STOP-BANG); CPAP if diagnosed	-	ROUTINE	ROUTINE
Stress management and emotional support (depression common post-stroke)	-	ROUTINE	ROUTINE
Influenza and pneumococcal vaccination	-	-	ROUTINE

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Hypoglycemia	Glucose <60; symptoms resolve with dextrose; diaphoresis, tremor	POC glucose STAT
Seizure with Todd's paralysis	Witnessed seizure, post-ictal confusion, resolves within 24h; may have known epilepsy	EEG, clinical observation, MRI (DWI negative)
Complicated migraine (hemiplegic)	Headache history, aura preceding deficit, gradual onset ("marching"), younger patient, family history	MRI DWI (negative), clinical history
Intracerebral hemorrhage	CT shows hemorrhage; more severe headache, rapid progression, vomiting	CT head without contrast
Brain tumor/mass	Subacute onset over days-weeks, progressive symptoms, headache worse in morning	MRI with contrast (enhancing mass)
Subdural hematoma	History of trauma or anticoagulation; subacute confusion, headache, fluctuating symptoms	CT head (crescent-shaped extra-axial collection)
Hypertensive encephalopathy / PRES	Severely elevated BP, headache, confusion, visual changes, seizures; typically posterior involvement	MRI FLAIR (posterior white matter edema), BP >220/120
CNS infection (abscess, meningitis)	Fever, meningismus, subacute course, immunocompromise	MRI with contrast, LP, blood cultures
Conversion disorder / functional neurological disorder	Non-anatomic distribution, Hoover sign positive, give-way weakness, distractible exam findings	Normal imaging, clinical exam findings
Peripheral vertigo (for posterior circulation symptoms)	Isolated vertigo, positive HINTS peripheral pattern, no other neurologic deficits	HINTS exam, MRI DWI
Multiple sclerosis exacerbation	Young patient, prior episodes, symptoms disseminated in space and time	MRI (periventricular/juxtacortical lesions), oligoclonal bands
Metabolic encephalopathy	Bilateral, non-focal exam (usually); abnormal metabolic labs; confusion predominates	BMP, ammonia, TSH, LFTs, UDS

6. MONITORING PARAMETERS¶

Parameter	ED	HOSP	OPD	ICU	Frequency	Target/Threshold	Action if Abnormal
NIHSS (NIH Stroke Scale)	STAT	STAT	ROUTINE	STAT	q1h x 24h (post-tPA: q15min x 2h, q30min x 6h, q1h x 16h), then q4h x 48h, then q shift	Stable or improving	If NIHSS increases ≥4 points: STAT CT head, call stroke team; consider hemorrhagic transformation, re-occlusion, or new stroke
Blood pressure	STAT	STAT	ROUTINE	STAT	Post-tPA: q15min x 2h, q30min x 6h, q1h x 16h; non-tPA: q1h x 24h, then q4h	Pre-tPA: <185/110; Post-tPA: <180/105 x 24h; Chronic: <130/80	Titrate antihypertensives; avoid SBP <100 (hypoperfusion risk)
Heart rate and rhythm (telemetry)	STAT	STAT	-	STAT	Continuous x 48-72h minimum	Detect paroxysmal atrial fibrillation, arrhythmias	Cardiology consult; anticoagulation if AF
Temperature	STAT	STAT	-	STAT	q4h x 48h, then q8h	Target <37.5°C (normothermia)	Acetaminophen; cooling measures; infection workup if >38°C
Blood glucose	STAT	STAT	ROUTINE	STAT	q6h x 48h (q1h if insulin drip)	140-180 mg/dL; avoid <60 mg/dL	Insulin; D50W for hypoglycemia
Oxygen saturation (SpO2)	STAT	STAT	-	STAT	Continuous x 24h, then q4h	≥94%	Supplemental O2; if <90% consider intubation for large strokes
Neurologic exam (level of consciousness, pupils)	STAT	STAT	-	STAT	q1-4h depending on severity	Alert, equal reactive pupils	Declining LOC: STAT CT, ICP management
Swallowing screen	URGENT	STAT	-	URGENT	Before any PO intake	Pass screening (water swallow test)	NPO until formal SLP evaluation
INR (if on warfarin)	-	ROUTINE	ROUTINE	-	Daily until stable, then per protocol	2.0-3.0 for AF; 2.5-3.5 for mechanical valve	Dose adjustment
Renal function (Cr, BUN)	-	ROUTINE	ROUTINE	-	q24-48h if contrast given or on new medications	Stable	Hydration; hold nephrotoxic agents
Lipid panel	-	ROUTINE	ROUTINE	-	Fasting within 24-48h; repeat at 4-12 weeks on statin	LDL <70 mg/dL	Intensify statin; add ezetimibe or PCSK9i
Depression screening (PHQ-9)	-	-	ROUTINE	-	At 1 month, 3 months, annually	PHQ-9 <5	SSRI initiation; psychology/psychiatry referral

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge home	Minor stroke (NIHSS 0-3) with stable exam, adequate support at home, able to perform ADLs or with home health, completed workup or reliable outpatient follow-up arranged, medications filled
Admit to stroke unit/floor	Moderate stroke (NIHSS 4-15), requires IV medications or ongoing monitoring, incomplete workup, dysphagia requiring NPO/modified diet, new atrial fibrillation requiring anticoagulation initiation
Admit to ICU/neuro-ICU	Post-tPA monitoring (first 24h), post-thrombectomy, large territory infarct with edema risk, posterior fossa stroke with herniation risk, unstable BP requiring IV antihypertensives, declining neurologic exam, respiratory compromise
Transfer to higher level of care	LVO needing thrombectomy (transfer to comprehensive stroke center), need for neurosurgical intervention not available, need for neuro-ICU not available
Inpatient rehabilitation	Moderate-severe deficits (NIHSS >4), able to participate in 3h/day therapy, expected to benefit from intensive rehab, medically stable
Skilled nursing facility (SNF)	Unable to tolerate 3h/day rehab, needs skilled nursing care, medically complex requiring ongoing monitoring
Home with outpatient therapy	Mild deficits, safe home environment, reliable follow-up, family support available

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
IV alteplase within 4.5h	Class I, Level A	AHA/ASA 2019 Guidelines (Powers et al.); NINDS trial (NEJM 1995); ECASS III (Hacke et al. NEJM 2008)
Tenecteplase non-inferior to alteplase for LVO	Class IIa, Level B-R	AcT trial (Menon et al. Lancet 2022); EXTEND-IA TNK
Thrombectomy for LVO 0-6h	Class I, Level A	MR CLEAN (Berkhemer et al. NEJM 2015), ESCAPE, EXTEND-IA, SWIFT-PRIME, REVASCAT
Thrombectomy for LVO 6-24h (selected patients)	Class I, Level A	DAWN trial (Nogueira et al. NEJM 2018); DEFUSE-3 (Albers et al. NEJM 2018)
DAPT 21 days for minor stroke/high-risk TIA	Class I, Level A	CHANCE trial (Wang et al. NEJM 2013); POINT trial
Aspirin + ticagrelor 30 days for minor stroke	Class IIa, Level B-R	THALES trial
High-intensity statin therapy	Class I, Level A	SPARCL trial (Amarenco et al. NEJM 2006); AHA/ASA 2021
Anticoagulation for AF-related stroke	Class I, Level A	RE-LY, ROCKET-AF, ARISTOTLE, ENGAGE AF
BP target <130/80 for secondary prevention	Class I, Level A	SPS3 trial; AHA/ASA 2021
Early mobilization (24-48h, not aggressive)	Class IIa, Level B-R	AVERT trial (very early <24h aggressive mobilization harmful)
Decompressive craniectomy for malignant MCA	Class I, Level A (age <60)	DESTINY, DECIMAL, HAMLET pooled analysis
Extended cardiac monitoring for cryptogenic stroke	Class IIa, Level B-R	CRYSTAL-AF, EMBRACE trials
Dysphagia screening before PO intake	Class I, Level B-NR	AHA/ASA 2019 Guidelines
Carotid endarterectomy for symptomatic stenosis ≥50%	Class I, Level A	NASCET, ECST trials
PFO closure for cryptogenic stroke age 18-60	Class IIa, Level B-R	CLOSE, RESPECT, REDUCE trials
Permissive hypertension (up to 220/120 if no tPA)	Class I, Level B-R	AHA/ASA 2019 Guidelines
Target glucose 140-180 mg/dL	Class I, Level C	AHA/ASA 2019 Guidelines
DVT prophylaxis within 24-48h	Class I, Level A	AHA/ASA 2019 Guidelines
Depression screening post-stroke	Class I, Level B-NR	AHA/ASA 2019 Guidelines
Normothermia maintenance	Class I, Level C	AHA/ASA 2019 Guidelines

APPENDIX: ACUTE STROKE TIME TARGETS

Metric	Target
Door-to-physician	≤10 minutes
Door-to-CT completion	≤25 minutes
Door-to-CT interpretation	≤45 minutes
Door-to-needle (tPA)	≤45 minutes (target), ≤60 minutes (acceptable)
Door-to-groin puncture (thrombectomy)	≤90 minutes (if on-site), ≤120 minutes (if transfer)
Last known well to tPA	≤4.5 hours
Last known well to thrombectomy	≤24 hours (with perfusion imaging selection for 6-24h)

APPENDIX: NIHSS QUICK REFERENCE

Score Range	Severity	General Prognosis
0	No deficit	Excellent
1-4	Minor stroke	Good; consider DAPT
5-15	Moderate stroke	Consider tPA; may need rehab
16-20	Moderate-severe	tPA + thrombectomy if LVO; likely inpatient rehab
21-42	Severe	High mortality/morbidity; goals of care discussion

APPENDIX: ASPECTS (Alberta Stroke Program Early CT Score)

Score	Interpretation
10	Normal CT
7-9	Small infarct; favorable for intervention
6	Threshold for thrombectomy eligibility (0-6h window)
<6	Large established infarct; higher hemorrhagic transformation risk
0	Complete MCA territory infarct