Acute Stroke Management

Diagnostic Evaluation

The American Heart Association recommends non-contrast CT head must be completed within 30 minutes of hospital admission to distinguish ischemic from hemorrhagic stroke 1, 2
The American Stroke Association suggests that if patient arrives within 6 hours and potentially eligible for endovascular thrombectomy, add CT angiography (CTA) from arch-to-vertex without delay 2
MRI with diffusion-weighted imaging (DWI) is an acceptable alternative to CT if available and doesn't delay treatment, as recommended by the American College of Radiology 1, 2

The American Academy of Neurology recommends neurological evaluation by stroke-experienced physician within 30 minutes of admission, available 24/7 1
The National Institute of Neurological Disorders and Stroke suggests that NIH Stroke Scale (NIHSS) assessment should be performed immediately and repeated multiple times daily to detect clinical deterioration 1
For thrombolysis candidates, the American Heart Association recommends neurological checks and vital signs every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 3

The American College of Cardiology recommends complete blood count with platelets, comprehensive metabolic panel, coagulation studies, and troponin for all patients with suspected acute stroke 1, 3
The American Diabetes Association suggests that hemoglobin A1C and fasting lipid panel should be measured for patients with suspected acute stroke 4

The American Heart Association recommends 12-lead ECG immediately without delaying stroke treatment, and continuous cardiac monitoring for 24-72 hours to detect atrial fibrillation and arrhythmias 1, 3, 5
Echocardiography (at least transthoracic) within 24 hours if no cardiac source identified, as recommended by the American Society of Echocardiography 4

The American College of Radiology recommends Doppler ultrasound of carotid/vertebral arteries within 24 hours, and CTA or MRA of cervical vessels for patients with suspected large vessel disease 1, 2, 4

The American Heart Association recommends maintaining blood pressure <185/110 mmHg before thrombolysis treatment, then <180/105 mmHg for 24 hours post-treatment, and avoiding aggressive BP lowering unless >220/120 mmHg for non-thrombolysis ischemic stroke 2
The American Academy of Neurology suggests monitoring temperature every 4 hours for first 48 hours, and treating fever >37.5°C (99.6°F) with acetaminophen 3, 5
The American Thoracic Society recommends maintaining oxygen saturation ≥92-94% with supplemental oxygen 2-3 L/min via nasal cannula as needed 3

The American College of Physicians recommends keeping patient NPO (including oral medications) until swallowing assessment completed, and head of bed positioning: 25-30° if increased intracranial pressure suspected; ≥30° if aspiration risk; head-flat position may maximize cerebral blood flow if no contraindications 3
The American Society of Health-System Pharmacists suggests that normal saline at 75-100 mL/hour should be administered, and maintaining adequate hydration 3, 5

The American Heart Association recommends that if thrombolysis given: NO heparin, warfarin, aspirin, clopidogrel, or dipyridamole for 24 hours, and if no thrombolysis: start antithrombotics within first 24 hours of admission (typically aspirin 160-325 mg) 3
The American College of Cardiology suggests that immediately discontinue anticoagulation and arrange reversal for hemorrhagic stroke 2, 5

The American College of Chest Physicians recommends intermittent pneumatic compression (IPC) devices bilaterally starting within 24 hours, and continuing until independently mobile, discharge, or 30 days, and low-molecular-weight heparin (enoxaparin) for high VTE risk patients; unfractionated heparin if renal failure 5

The American Academy of Neurology recommends treating acute seizures with short-acting medications (lorazepam IV) if not self-limiting, and do NOT start prophylactic anticonvulsants 2, 5
The American Epilepsy Society suggests that single self-limiting seizure at onset does not require long-term anticonvulsants 2, 5

The American Heart Association recommends never giving aspirin or antithrombotics before brain imaging rules out hemorrhage, and never delay imaging for laboratory results (except coagulation studies for thrombolysis candidates) 1, 2, 3
The American College of Radiology suggests never using contrast-enhanced CT initially as it may obscure hemorrhage, and never delay door-to-needle time beyond 60 minutes (target ≤30 minutes) 1, 6