Acute Ischemic Stroke Evaluation and Immediate Management

Patient Presentation and Initial Data Collection

A structured acute ischemic stroke case presentation must include patient demographics, exact symptom onset time, NIHSS score, vital signs with specific blood‑pressure values, non‑contrast CT findings, eligibility for reperfusion therapy according to NINDS and ECASS III criteria, and immediate secondary‑prevention measures to enable rapid decisions within the 4.5‑hour thrombolysis window. [@1]
Age > 80 years is an exclusion criterion for intravenous thrombolysis in the 3–4.5 hour (ECASS III) window (but not for the 0–3 hour NINDS window). [@1]
Exact time of symptom onset (last known well) must be documented because it determines eligibility for all reperfusion therapies. [@1]
Prior stroke or head injury within the previous 3 months, major surgery within 14 days, a history of intracranial hemorrhage, recent gastrointestinal/genitourinary bleeding within 21 days, myocardial infarction within 3 months, diabetes combined with prior stroke, and current anticoagulant use are all exclusion factors for thrombolysis. [@1]
The NIHSS must be calculated and recorded; it quantifies deficit severity, guides treatment eligibility, predicts prognosis, and determines appropriate admission location. [@6]

For intravenous thrombolysis candidates, systolic/diastolic blood pressure must be < 185/110 mm Hg before treatment and maintained < 180/105 mm Hg for the first 24 hours after therapy. [@1]
Immediate assessment of oxygen saturation and respiratory status is required. [@6]
A 12‑lead ECG should be obtained promptly to identify atrial fibrillation, although it may be deferred until after the thrombolysis decision if the patient is hemodynamically stable. [@6]

Non‑contrast head CT must be performed emergently and must document the presence or absence of intracranial hemorrhage. [@1]
Extent of early ischemic change exceeding > 1/3 of the middle‑cerebral‑artery territory excludes patients from ECASS III thrombolysis. [@1]
CT angiography should be obtained without delaying thrombolysis to identify large‑vessel occlusions that qualify for mechanical thrombectomy within 24 hours. [@6]
The initial CT scan should be completed within 25 minutes of hospital arrival. [@8]

Point‑of‑care glucose < 50 mg/dL or > 400 mg/dL is an exclusion criterion for NINDS‑window thrombolysis. [@1]
INR > 1.7 excludes patients from ECASS III thrombolysis; INR > 1.6 excludes patients from NINDS‑window thrombolysis. [@1]
Any use of oral anticoagulants (regardless of INR) excludes patients from ECASS III‑window thrombolysis. [@1]
Platelet count < 100 × 10⁹/L is an absolute contraindication to thrombolysis. [@1]
Routine laboratory panels (CBC, electrolytes, creatinine, troponin) should be drawn but must not delay reperfusion therapy. [@6]

NINDS (0–3 h) criteria: acute ischemic stroke with a clearly defined onset time, a measurable deficit on NIHSS, a non‑contrast CT showing no hemorrhage, and absence of any listed exclusion criteria. [@1]
ECASS III (3–4.5 h) additional exclusions: age > 80 years, NIHSS > 25, combined prior stroke + diabetes mellitus, and any oral anticoagulant use. [@1]
Alteplase dosing is 0.9 mg/kg (maximum 90 mg), with 10 % given as an initial bolus and the remaining 90 % infused over 60 minutes. [@5]

Patients with anterior‑circulation large‑vessel occlusion and disabling deficits should receive mechanical thrombectomy without waiting for a response to intravenous thrombolysis when indicated. [@6]

A validated swallowing screen must be completed before any oral intake, ideally within 24 hours of presentation. [@6]
Prolonged cardiac rhythm monitoring for at least 2 weeks (up to 30 days) is required to detect paroxysmal atrial fibrillation in patients ≥ 55 years without known AF. [@10]
Transthoracic or transesophageal echocardiography should be performed when a cardiac source of embolism is suspected; findings alter management in ≈ 16–20 % of cases. [@10]
Carotid imaging is mandatory to identify symptomatic stenosis that may require revascularization. [@10]

Do not delay thrombolysis while awaiting laboratory results unless a specific contraindication (e.g., INR for a patient on warfarin) is suspected. [@6]
Do not discharge a patient from the emergency department without completing the full diagnostic work‑up, functional assessment, and secondary‑prevention plan. [@6]
Do not rely on a single ECG to rule out atrial fibrillation; prolonged monitoring up to 30 days is necessary. [@10]