Acute Stroke Diagnosis and Management

Initial Assessment and Eligibility for Thrombolytic Therapy

The American Heart Association recommends establishing the time of symptom onset to determine eligibility for thrombolytic therapy and endovascular intervention 1, 2
The American College of Cardiology suggests asking specifically when the patient was last at baseline neurological function to establish the exact symptom onset time 1, 2
If the patient woke with symptoms, the "last known well" time is when they went to sleep, not when they woke 1
This information determines whether the patient qualifies for IV tPA (within 4.5 hours) or endovascular thrombectomy (up to 24 hours for select patients) 2

The American Heart Association recommends using the Cincinnati Prehospital Stroke Scale (CPSS) immediately to check for three findings: facial droop, arm drift, and abnormal speech 1
A single abnormality on CPSS has a 72% probability of stroke 1
The National Institutes of Health recommends performing the full 11-item National Institutes of Health Stroke Scale (NIHSS) to assess level of consciousness, gaze, visual fields, facial palsy, motor arm and leg, limb ataxia, sensory, language/aphasia, dysarthria, and extinction/inattention 3, 2

The American Heart Association suggests documenting vascular risk factors, including hypertension, diabetes mellitus, atrial fibrillation, prior stroke or TIA, smoking status, hyperlipidemia, and coronary artery disease or peripheral vascular disease 2
The American College of Cardiology recommends assessing critical associated symptoms, including visual changes, sensory symptoms, gait/balance, headache, and level of consciousness 1, 4, 2

The American Heart Association recommends assessing vital signs, including blood pressure and oxygen saturation, and performing a complete NIHSS examination 4, 2, 3
The American College of Cardiology suggests completing laboratory tests, including complete blood count with platelets, serum electrolytes and creatinine, and troponin, within 60 minutes 2, 4
The American Heart Association recommends non-contrast CT head as the minimum required imaging to exclude intracranial hemorrhage before thrombolysis 2

The American College of Cardiology recommends completing CT angiography or MR angiography from aortic arch to vertex within 24 hours to identify large vessel occlusion requiring endovascular thrombectomy 5
The American Heart Association suggests avoiding common pitfalls, including delaying care to obtain extensive vascular imaging, treating hypertension aggressively, missing the time window, assuming isolated dysarthria is benign, and failing to recognize brainstem stroke 2, 4, 6