Acute Ischemic Stroke Evaluation and Management in Adults

Immediate Clinical Assessment

Obtain the exact time of symptom onset or last known normal to determine eligibility for intravenous thrombolysis – essential for all patients presenting with possible stroke. 1
Perform the full 11‑item NIH Stroke Scale (NIHSS) at the bedside to quantify deficit severity; a score < 5 suggests a small stroke, whereas a score > 20 indicates a large stroke. [1][2]

Non‑contrast CT of the head is the first imaging study to exclude intracerebral hemorrhage before thrombolysis and must be completed and interpreted within 25 minutes of emergency‑department arrival to meet quality benchmarks. [1][3]

Baseline CBC, electrolytes, glucose, and coagulation profile are required before administering IV tPA to identify contraindications such as coagulopathy or severe hypoglycemia. 1
A 12‑lead ECG should be obtained promptly to detect atrial fibrillation or acute cardiac ischemia that may underlie the stroke. 4

Approximately 50 % of suspected in‑hospital strokes are ultimately identified as stroke mimics; therefore, systematic evaluation for metabolic, toxic, infectious, and medication‑related causes is mandatory. 3
Altered mental status without focal neurological findings is more likely a mimic than a true stroke. 3

IV tPA administered within 4.5 hours of symptom onset improves functional outcome; the number needed to treat is 8.3 to achieve minimal or no disability (modified Rankin 0‑1) at 90 days. 1
In tPA‑treated patients, 39 % achieve a modified Rankin score of 0‑1 versus 26 % with placebo, demonstrating a clinically meaningful benefit across both early (0‑90 min) and later (91‑180 min) windows. 1
Symptomatic intracerebral hemorrhage occurs in ≈ 6 % of tPA recipients compared with 0.6 % of placebo patients, yet 90‑day mortality is similar (17 % vs 21 %). This risk is accepted given the overall benefit. [1][2]

Correct metabolic derangements (e.g., hypoglycemia, electrolyte abnormalities, uremia) promptly. 4
Treat identified infections with appropriate antibiotics. 3
Discontinue or reverse offending sedative or anticholinergic agents. 4
Provide supportive care including supplemental oxygen, hemodynamic support, and pain control. 4

Admit confirmed stroke patients to a dedicated stroke unit or ICU for continuous monitoring. 1
Initiate secondary prevention measures immediately: antiplatelet therapy, high‑intensity statin, and blood‑pressure control. 1
Screen for post‑stroke cognitive and emotional disturbances using validated tools (e.g., MoCA, HADS) during follow‑up. 8

Do not delay imaging while attempting “conservative” management; urgent imaging is required when neurological deficits are present. 5
Do not wait for spontaneous resolution of deficits before activating stroke pathways, as this leads to critical treatment delays. 3
Do not attribute new neurological deficits solely to anesthesia without first excluding stroke. 3

All facts are presented in English, with citation identifiers indicating the supporting source.