Submodule
Recognition and Stroke Systems
Time starts at last known well, but disability, destination, local transfer performance, and parallel emergency work determine whether time becomes treatment.
- Last known well
- Disabling deficit
- Prehospital destination
- Stroke mimics
- Mobile stroke units
Record last known well
Preserve rapid transfer
Do not delay eligible IV therapy
Use independent eligibility pathways
Start with time and function
Document last known well rather than discovery time. Use NIHSS consistently, but decide whether a deficit is disabling through language, vision, gait, dominant-hand function, occupation, baseline independence, and patient goals. A low score can still represent profound disability.
Run mimic evaluation in parallel
Check glucose immediately and assess seizure, migraine, infection, toxic-metabolic disease, trauma, and other mimics without waiting for exhaustive exclusion. Brain imaging, history, medications, pressure, airway, and reperfusion eligibility proceed together.
Choose destination through the network
The best destination depends on local travel, thrombolysis capability, EVT access, mobile stroke units, and transfer performance. Direct EVT-center transport can help when the regional system supports it, while a poorly planned bypass can delay all therapy.
Measure the system
Track recognition, scene time, prenotification, door-to-imaging, door-to-needle, vessel-imaging time, transfer acceptance, door-in-door-out, reperfusion, complications, function, and access across geography and patient groups.
Quick check
Submodule
Imaging and Reperfusion Selection
Basic imaging excludes hemorrhage, vascular imaging identifies a retrieval target, and advanced imaging selects tissue when the clock alone is insufficient.
- Noncontrast CT
- CTA or MRA
- Core and penumbra
- Extended-window thrombolysis
- Large-vessel occlusion
A low score can still disable
Do not wait for every test
Activate EVT pathway
Select extended windows
Exclude hemorrhage first
Rapid noncontrast CT or MRI identifies intracranial hemorrhage and major established injury. Most early-window thrombolysis decisions do not require advanced imaging. Glucose and essential history occur in parallel.
Find the occluded vessel
Urgent CTA or MRA identifies LVO, tandem disease, and the EVT target. Activate neurointervention and transfer while IV thrombolysis is evaluated independently. Do not wait to see whether IV therapy works.
Interpret tissue as an estimate
Core is tissue likely irreversibly injured and penumbra is threatened hypoperfused tissue. Perfusion and diffusion-FLAIR mismatch can select unknown-onset or 4.5-to-9-hour thrombolysis candidates and late EVT candidates, but image quality and software uncertainty remain clinical concerns.
Do not use an outdated exclusion
Selected patients with large ischemic cores can benefit from EVT. Time, occlusion, core method, collaterals, deficit, baseline function, hemorrhage, and goals are interpreted together.
Quick check
Submodule
Intravenous Thrombolysis
The 2026 guideline supports alteplase or tenecteplase within 4.5 hours for eligible disabling deficits, with imaging-selected extension for selected patients.
- Alteplase dose
- Tenecteplase stroke dose
- Blood-pressure thresholds
- Nondisabling stroke
- Hemorrhage surveillance
Do not wait for improvement
Use exact dose and preparation
Avoid adjuvant antithrombotics
Image before antithrombotics
Use either endorsed agent precisely
Alteplase is 0.9 mg/kg to 90 mg, with 10 percent as a bolus and the remainder over 60 minutes. Tenecteplase is 0.25 mg/kg to 25 mg as a single bolus under the 2026 guideline. Never import the higher STEMI tenecteplase dose into stroke care.
Separate guideline from label
The 2026 guideline endorses either agent within 4.5 hours for eligible disabling AIS. The current US tenecteplase label should still be checked because labeled timing and institutional protocols can differ from professional guidance.
Control pressure without collapsing perfusion
Reduce pressure below 185 over 110 before thrombolysis and maintain below 180 over 105 afterward. Use frequent measurements and protocolized agents while avoiding hypotension and treatment delay.
Monitor before adding antithrombotics
Perform frequent neurologic and pressure checks. New headache, vomiting, hypertension, bleeding, or neurologic decline requires urgent imaging. Obtain follow-up imaging before routine antiplatelet or anticoagulant therapy after thrombolysis.
Quick check
Submodule
Endovascular Thrombectomy
Modern EVT includes selected early and late anterior LVO, large-core infarction, basilar occlusion, and carefully selected pediatric stroke.
- Anterior LVO
- Late window
- Large core
- Basilar occlusion
- Pediatric EVT
Early and selected late windows
Core size is not an automatic exclusion
Treat within 24 hours when eligible
Do not withhold one while arranging the other
Treat the artery quickly
Proximal anterior-circulation LVO benefits from rapid EVT. IV thrombolysis and thrombectomy are not mutually exclusive. Give eligible IV therapy without waiting to judge recanalization, while the EVT team and transfer move forward.
Use tissue beyond the early clock
Selected patients can benefit up to 24 hours. Collaterals can preserve threatened tissue. Current criteria interpret time, imaging, occlusion, deficit, baseline function, and goals rather than applying a universal six-hour stop.
Include selected large cores
Randomized evidence supports EVT in selected patients with larger established cores. Core size still informs prognosis and risk, but it should not be used as an automatic outdated exclusion.
Recognize basilar and pediatric pathways
Eligible basilar occlusion within 24 hours with NIHSS at least 10 has a strong EVT recommendation. Children require a specialized pathway that accounts for age, vessel size, etiology, dosing, imaging, consent, and pediatric expertise.
Quick check
Submodule
Supportive Care and Complications
Brain outcome depends on perfusion, oxygen, metabolic safety, swallowing, mobility, hemorrhage detection, and edema response after reperfusion decisions are made.
- Blood pressure
- Glucose and fever
- Dysphagia
- VTE prevention
- Cerebral edema
No routine target below 140 after EVT
Avoid intensive 80 to 130 control
Prevent aspiration
Escalate early
Avoid pressure extremes
Prevent hypotension and treat competing hypertensive emergencies. Without reperfusion therapy, routine lowering is often deferred unless pressure is markedly elevated. After IVT or EVT, follow protocol ceilings, but do not intensively lower systolic pressure below 140 solely because reperfusion succeeded.
Protect metabolic stability
Correct hypoglycemia, manage clinically important hyperglycemia, and treat fever causes. Intensive glucose control to 80 to 130 mg/dL does not improve outcome and increases severe hypoglycemia.
Screen swallowing before oral intake
Keep the patient without food, water, or oral medication until a validated swallow screen. Failed screening prompts specialist assessment and an alternate medication and nutrition plan. Silent aspiration can occur without dramatic coughing.
Escalate edema and hemorrhage early
Neurologic decline requires immediate reassessment and imaging. Large hemispheric or cerebellar infarction may need osmotic therapy and early decompressive surgery planning. Do not wait for fixed pupils or irreversible brainstem compression.
Quick check
Submodule
Etiology, Prevention, and Transition
Acute success becomes durable only when the stroke mechanism, antithrombotic plan, risk therapy, rehabilitation, education, and follow-up responsibility are explicit.
- Mechanism
- Antithrombotic timing
- Risk reduction
- Rehabilitation
- Follow-up ownership
Do not label cryptogenic too early
Avoid unnecessary combination
Measure function beyond NIHSS
Close access gaps
Define the mechanism
Use infarct pattern, head and neck vascular imaging, telemetry, cardiac testing when indicated, medications, and targeted laboratory evaluation to distinguish cardioembolism, large-artery disease, small-vessel disease, and other causes. Do not call a stroke cryptogenic before adequate evaluation.
Match antithrombotic to cause
Antiplatelet therapy treats most noncardioembolic stroke, while anticoagulation is used for eligible cardioembolic sources such as atrial fibrillation. Short dual antiplatelet therapy fits selected minor nondisabling stroke or high-risk TIA, not indefinite routine combination treatment.
Start recovery and prevention together
Address LDL, pressure, diabetes, tobacco, sleep, activity, nutrition, adherence, and access. Begin physical, occupational, speech, swallowing, cognitive, and psychological rehabilitation according to deficit rather than waiting for spontaneous recovery.
Close the handoff
Provide warning signs, medication purpose, bleeding precautions, driving and activity guidance, rehabilitation schedule, pending tests, and named follow-up ownership. Include caregivers and communication support while preserving patient autonomy.
Quick check
Module test
Check the connections.
Each attempt draws 10 questions from the complete 100 question bank.
Each attempt draws a fresh set and rearranges the answer choices.
References
Current clinical foundation.
Lecture material was synthesized with the following contemporary guidance. Verify local policy and current guidance before applying clinical information.