An evidence-based training module aligned with AHA/ASA 2024-2025 guidelines. Master stroke recognition, acute assessment, and treatment pathways to improve patient outcomes in time-critical scenarios.
A stroke occurs when blood flow to a region of the brain is interrupted, causing neuronal injury within minutes. Rapid classification guides treatment decisions and directly affects patient outcomes.
Accounts for approximately 87% of all strokes. Caused by arterial occlusion from thrombosis or embolism. The ischemic penumbra — tissue at risk but not yet infarcted — is the target of acute intervention.
Accounts for approximately 13% of strokes but carries higher mortality. Includes intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Often related to hypertension or vascular malformations.
Transient neurological deficit without infarction on imaging. A TIA is a medical emergency and a warning sign: 10-15% of TIA patients will have a stroke within 90 days, with highest risk in the first 48 hours.
Occlusion of a major cerebral artery (ICA, M1/M2 MCA, basilar). Causes severe deficits and is amenable to mechanical thrombectomy. LVO identification drives transfer and treatment decisions.
Involves the vertebrobasilar system. Presents with vertigo, diplopia, ataxia, dysarthria, and visual field deficits. Commonly misdiagnosed as peripheral vertigo or migraine, leading to delayed treatment.
Key takeaway: Time is brain. Each minute of untreated large vessel occlusion destroys approximately 1.9 million neurons. Rapid classification of stroke type determines the treatment pathway.
The BE-FAST mnemonic expands on the traditional FAST assessment to capture posterior circulation strokes that are frequently missed. Use BE-FAST for systematic screening of all suspected stroke patients.
Sudden loss of balance or coordination, difficulty walking, or new-onset gait instability. Key indicator of posterior circulation involvement.
Sudden visual changes: blurred or double vision (diplopia), visual field cuts, or loss of vision in one or both eyes. Screen by testing each eye independently.
Facial droop or asymmetry. Ask the patient to smile and show teeth. One side that does not move or droops indicates facial nerve involvement.
Arm weakness or drift. Ask the patient to raise both arms and hold for 10 seconds. Unilateral drift or inability to raise indicates motor deficit.
Slurred speech (dysarthria) or inability to speak or understand language (aphasia). Ask the patient to repeat a simple phrase.
Establish last known well (LKW) time immediately. This is the single most critical piece of information for treatment eligibility. Call emergency services without delay.
Why BE-FAST matters: The traditional FAST mnemonic misses up to 14% of strokes, particularly posterior circulation events. Adding Balance and Eyes improves detection sensitivity to greater than 95%.
The National Institutes of Health Stroke Scale (NIHSS) is the standardized clinical assessment tool for quantifying stroke severity. It guides treatment decisions, predicts outcomes, and is required for thrombolytic and thrombectomy eligibility documentation.
| Domain | Assessment |
|---|---|
| 1a. Level of consciousness | Alert, drowsy, stuporous, comatose |
| 1b. LOC questions | Month and age |
| 1c. LOC commands | Open/close eyes, grip/release hand |
| 2. Best gaze | Horizontal eye movements |
| 3. Visual fields | Visual field testing by confrontation |
| 4. Facial palsy | Symmetry of facial movements |
| 5. Motor arm (L and R) | Arm drift at 90 degrees (sitting) or 45 degrees (supine) |
| 6. Motor leg (L and R) | Leg drift at 30 degrees supine |
| 7. Limb ataxia | Finger-nose and heel-shin testing |
| 8. Sensory | Pin prick to face, arm, trunk, and leg |
| 9. Best language | Naming, reading, describing a picture |
| 10. Dysarthria | Clarity of speech reading a word list |
| 11. Extinction/inattention | Double simultaneous stimulation |
Normal examination. Does not rule out TIA or minor stroke — imaging still indicated if clinical suspicion exists.
Mild deficits. IV thrombolysis may still be indicated depending on disabling nature of symptoms.
Significant deficits. Strong indication for thrombolysis. Consider LVO screening for thrombectomy eligibility.
Major deficits. High probability of LVO. Urgent CTA and thrombectomy evaluation required.
Clinical pearl: An NIHSS score of 6 or greater has high sensitivity for large vessel occlusion. However, posterior circulation LVO can present with a deceptively low NIHSS. Always obtain CTA when LVO is suspected regardless of score.
Neuroimaging is the gatekeeper of acute stroke treatment. The primary goals are to exclude hemorrhage, identify ischemia, and evaluate for large vessel occlusion — all within strict time constraints.
First-line imaging. Must be obtained and interpreted within 20 minutes of arrival. Primary purpose: exclude hemorrhage. Early ischemic changes may be subtle or absent.
Evaluates for large vessel occlusion. Should be obtained simultaneously with or immediately after non-contrast CT. Critical for thrombectomy triage.
Maps ischemic core versus salvageable penumbra. Required for extended-window thrombectomy (6-24 hours). RAPID software automates mismatch analysis.
| Metric | Target |
|---|---|
| Door to CT interpretation | < 20 minutes |
| Door to needle (IV thrombolysis) | < 60 minutes |
| Door to groin puncture (thrombectomy) | < 90 minutes |
| IV alteplase window | 0 - 4.5 hours from LKW |
| Thrombectomy (standard window) | 0 - 6 hours from LKW |
| Thrombectomy (extended window) | 6 - 24 hours with favorable perfusion imaging |
The DAWN and DEFUSE 3 trials demonstrated that select patients benefit from thrombectomy up to 24 hours from last known well when perfusion imaging shows a favorable mismatch: a small ischemic core relative to a large area of salvageable penumbra. RAPID software provides automated volumetric analysis to identify eligible patients.
Key takeaway: Never let a perfusion scan delay treatment in the standard window. In extended-window patients, perfusion imaging is the key to identifying who can still benefit from intervention.
IV thrombolysis remains the first-line pharmacologic treatment for acute ischemic stroke. Understanding eligibility criteria, dosing, and concurrent management is essential for every member of the stroke team.
Tenecteplase (0.25 mg/kg, max 25 mg, single IV bolus) is emerging as an alternative to alteplase. Advantages include single-bolus administration, ease of use, and growing evidence of non-inferiority. It is increasingly used as a bridging agent before thrombectomy.
| Scenario | BP Target |
|---|---|
| Pre-thrombolysis eligibility | < 185/110 mmHg |
| During and 24h post-thrombolysis | < 180/105 mmHg |
| No thrombolysis planned | Permissive hypertension unless > 220/120 |
Critical reminder: Do not delay IV thrombolysis to obtain laboratory results unless there is clinical suspicion of bleeding diathesis or anticoagulant use. Blood glucose is the only lab required before treatment initiation.
Mechanical thrombectomy has revolutionized treatment of large vessel occlusion stroke. Identifying LVO early and expediting transfer to a thrombectomy-capable center is a critical competency for all stroke clinicians.
Rapid Arterial oCclusion Evaluation. Scores 0-9, evaluating facial palsy, arm motor, leg motor, head/gaze deviation, and aphasia/agnosia. Score of 5 or greater suggests LVO.
Los Angeles Motor Scale. Scores 0-5, assessing facial droop, arm drift, and grip strength. Score of 4 or greater suggests LVO. Quick to perform in the field.
NIHSS of 6 or greater raises suspicion for LVO. Gaze deviation, aphasia, and neglect in combination are particularly predictive. CTA is the definitive diagnostic tool.
| Model | Description |
|---|---|
| Drip-and-ship | Administer IV thrombolysis at nearest PSC, then transfer to CSC for thrombectomy. Faster treatment initiation, but adds transfer time. |
| Mothership | Bypass local PSC and transport directly to CSC. Optimal when CSC is within 30-minute additional transport time. Avoids inter-facility transfer delays. |
Key takeaway: IV thrombolysis should never be delayed for thrombectomy. Administer tPA at the earliest opportunity, then arrange transfer for thrombectomy. The two treatments are complementary, not competitive.
Hemorrhagic stroke requires a distinct management approach focused on hemostasis, blood pressure control, and preventing hematoma expansion. Secondary prevention strategies are essential to reduce recurrence risk for all stroke types.
The ICH Score predicts 30-day mortality using five variables:
Acute intensive blood pressure lowering to a target systolic BP of 140 mmHg within the first hour is recommended for ICH patients presenting with systolic BP between 150-220 mmHg. Use IV labetalol or nicardipine infusion for rapid, titratable control.
Administer IV vitamin K plus 4-factor prothrombin complex concentrate (4F-PCC). Target INR less than 1.3 within 60 minutes. Do not rely on FFP alone.
Idarucizumab for dabigatran. Andexanet alfa for factor Xa inhibitors (rivaroxaban, apixaban). Administer immediately without waiting for drug levels.
Critical distinction: Hemorrhagic stroke management is the opposite of ischemic management in several key areas — aggressively lower blood pressure, reverse anticoagulation, and avoid antithrombotics in the acute setting.
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Elena is brought to the ED by EMS with sudden-onset right-sided weakness and difficulty speaking. Symptom onset was witnessed 45 minutes ago. She is alert but unable to produce fluent speech. Right arm drift is present. BP 178/96, HR 88, SpO2 97% on room air, glucose 142 mg/dL. No history of recent surgery or bleeding.
Robert's wife found him on the floor at 6:30 AM with left-sided weakness and slurred speech. He was last seen normal at 10:00 PM the night before (8.5 hours ago). He is drowsy but arousable. Left facial droop, left arm and leg plegia. BP 192/104, HR 76, SpO2 95% on 2L nasal cannula, glucose 188 mg/dL. History of hypertension and atrial fibrillation (on apixaban).
Ana presents to the ED with sudden-onset severe vertigo, double vision, and difficulty walking that began 2 hours ago. She has been vomiting. The triage nurse initially categorizes this as an inner ear problem. On your exam: rightward gaze nystagmus, diplopia on lateral gaze, right-sided limb ataxia, dysarthria. BP 168/92, HR 82, glucose 110 mg/dL.
David presents with sudden-onset worst headache of his life followed by vomiting and rapid decline in consciousness. On arrival his GCS is 9 (E2V3M4). He has left pupil dilation and right hemiplegia. BP 228/118, HR 62, SpO2 94% on room air. History of uncontrolled hypertension. He is not on anticoagulants.
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