managing-acute-stroke

# Managing Acute Stroke

Follows the time-critical stroke pathway from door-to-needle with NIHSS scoring, tPA eligibility criteria, and large-vessel occlusion screening for mechanical thrombectomy.

## Why This Skill Exists

Stroke is the fifth leading cause of death in the United States and the leading cause of long-term disability. For ischemic stroke, the phrase "time is brain" reflects the reality that approximately 1.9 million neurons are lost per minute of untreated large-vessel occlusion. IV alteplase (tPA) administered within 4.5 hours of symptom onset reduces disability, and mechanical thrombectomy extends the treatment window to 24 hours for selected patients with large-vessel occlusion and salvageable brain tissue.

The AHA/ASA Target: Stroke initiative sets a benchmark of door-to-needle time ≤60 minutes for IV tPA, with aspirational goal of ≤45 minutes. CMS Stroke Core Measures (STK-1 through STK-10) track performance metrics including DVT prophylaxis, antithrombotic therapy, anticoagulation for atrial fibrillation, statin therapy, and dysphagia screening. Failure to meet these metrics affects hospital quality ratings, reimbursement, and accreditation as a Stroke Center (Primary, Thrombectomy-Capable, or Comprehensive). This skill ensures protocol-driven stroke management that meets AHA/ASA standards and CMS core measures.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the time of symptom onset or last known well (LKW)? (Default: determine by patient, family, or EMS report — this is the most critical data point)
2. What are the presenting neurologic deficits? (Default: document specific deficits before formal NIHSS)
3. What is the patient's blood glucose? (Default: obtain point-of-care glucose immediately — hypoglycemia is a stroke mimic)
4. What is the patient's current blood pressure? (Default: document and manage per protocol)
5. Is the patient on anticoagulants? (Default: query medication list — affects tPA eligibility)
6. What is the patient's baseline functional status? (Default: document pre-stroke mRS)
7. Are there contraindications to thrombolytics? (Default: screen checklist before tPA)
8. Is large-vessel occlusion suspected? (Default: screen using NIHSS ≥6 or RACE/LAMS score)

### Documents to Request

- EMS stroke alert documentation with LKW time
- Medication list (focus on anticoagulants: warfarin, DOACs, heparin)
- Recent INR or anti-Xa level if on anticoagulation
- Prior brain imaging (CT, MRI)
- Baseline neurologic status and functional level (pre-morbid mRS)
- Advance directives or healthcare proxy information
- Recent surgical history (within 14 days = relative tPA contraindication)

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## Step 1: Stroke Alert Activation and Immediate Actions

### Time-Zero Actions (within minutes of arrival)

| Time Target | Action |
|-------------|--------|
| 0 min | Stroke alert activated; patient to CT scanner |
| ≤10 min | Point-of-care glucose obtained (if <60 mg/dL, treat and reassess — hypoglycemia is a stroke mimic) |
| ≤15 min | Non-contrast CT head completed |
| ≤20 min | CT interpreted by physician (rule out hemorrhage) |
| ≤25 min | NIHSS scored and documented |
| ≤45 min | IV tPA bolus administered if eligible (door-to-needle target) |
| ≤60 min | Absolute maximum door-to-needle time per AHA/ASA |

### Non-Contrast CT Head Interpretation

| Finding | Action |
|---------|--------|
| No hemorrhage, no large completed infarct | Proceed to tPA eligibility screening |
| Intracerebral hemorrhage | Abort tPA pathway; manage per ICH protocol; neurosurgery consult |
| Large hypodensity >1/3 MCA territory | Relative contraindication to tPA (increased hemorrhagic conversion risk) |
| Hyperdense vessel sign | Suggests large-vessel occlusion → CTA |

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## Step 2: NIHSS Scoring

The NIH Stroke Scale is a 15-item neurologic examination scored 0-42. Perform and document the complete scale.

| Item | Assessment | Score Range |
|------|-----------|-------------|
| 1a | Level of consciousness | 0-3 |
| 1b | LOC questions (month, age) | 0-2 |
| 1c | LOC commands (open/close eyes, grip/release) | 0-2 |
| 2 | Best gaze (horizontal eye movement) | 0-2 |
| 3 | Visual fields | 0-3 |
| 4 | Facial palsy | 0-3 |
| 5a | Motor — left arm (drift test, 10 sec) | 0-4 |
| 5b | Motor — right arm (drift test, 10 sec) | 0-4 |
| 6a | Motor — left leg (drift test, 5 sec) | 0-4 |
| 6b | Motor — right leg (drift test, 5 sec) | 0-4 |
| 7 | Limb ataxia | 0-2 |
| 8 | Sensory | 0-2 |
| 9 | Best language (aphasia) | 0-3 |
| 10 | Dysarthria | 0-2 |
| 11 | Extinction/inattention (neglect) | 0-2 |

**Severity interpretation:**

| NIHSS | Severity | Notes |
|-------|----------|-------|
| 0 | No deficit | Consider stroke mimic |
| 1-4 | Minor | tPA benefit debated; consider if disabling deficit |
| 5-15 | Moderate | Clear tPA benefit if within window |
| 16-20 | Moderate-severe | tPA benefit present; consider thrombectomy |
| 21-42 | Severe | tPA benefit present; high priority for thrombectomy if LVO |

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## Step 3: IV Alteplase (tPA) Eligibility and Administration

### Inclusion Criteria (all must be met)
- Diagnosis of ischemic stroke with measurable neurologic deficit
- Symptom onset (or LKW) within 4.5 hours
- Age ≥18 years
- CT head without hemorrhage

### Absolute Contraindications
- Active internal bleeding (excluding menses)
- History of intracranial hemorrhage
- Intracranial neoplasm, AVM, or aneurysm
- Recent (within 3 months) intracranial or spinal surgery, serious head trauma, or prior stroke
- Arterial puncture at non-compressible site within 7 days
- Current severe uncontrolled hypertension (SBP >185 or DBP >110 despite treatment)
- Blood glucose <50 mg/dL
- Platelet count <100,000
- INR >1.7 or PT >15 seconds
- Heparin within 48 hours with elevated aPTT
- DOAC within 48 hours (unless anti-Xa level is below treatment range)

### Additional Exclusions for 3-4.5 Hour Window
- Age >80 (relative in current guidelines — benefit still likely)
- NIHSS >25
- History of both diabetes AND prior stroke
- Oral anticoagulant use regardless of INR

### tPA Administration Protocol
- **Dose:** 0.9 mg/kg (maximum 90 mg)
- **Administration:** 10% as IV bolus over 1 minute, remaining 90% infused over 60 minutes
- **Blood pressure management:** Maintain SBP <180, DBP <105 for 24 hours post-tPA
- **Post-tPA monitoring:** Neuro checks every 15 minutes during infusion, every 30 minutes for 6 hours, then hourly for 18 hours
- **No anticoagulants or antiplatelets for 24 hours** after tPA; repeat CT at 24h before starting

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## Step 4: Large-Vessel Occlusion and Thrombectomy Screening

### LVO Screening Indicators
- NIHSS ≥6 (sensitivity ~85% for LVO)
- Cortical signs: aphasia, neglect, gaze deviation
- RACE score ≥5 or LAMS score ≥4

### CTA Head and Neck
- Obtain emergently if LVO suspected
- Evaluate for: ICA occlusion, M1/M2 MCA occlusion, basilar occlusion
- ASPECTS score (Alberta Stroke Program Early CT Score): ≥6 = favorable for thrombectomy

### Thrombectomy Eligibility (AHA/ASA 2019)
- **0-6 hours:** LVO (ICA or M1 MCA), pre-stroke mRS 0-1, ASPECTS ≥6, age ≥18
- **6-24 hours (DAWN/DEFUSE 3 criteria):** Perfusion imaging (CT perfusion or MRI DWI/PWI) showing mismatch between core infarct and penumbra; clinical-imaging mismatch criteria met
- Coordinate transfer to thrombectomy-capable center if not available on-site

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## Step 5: Post-Acute Management and Quality Metrics

### Stroke Unit Orders
- NPO until dysphagia screening completed (CMS STK-4)
- DVT prophylaxis within 48 hours (CMS STK-1)
- Antithrombotic therapy within 48 hours of admission (CMS STK-2) — NOT within 24h of tPA
- Statin therapy initiated (CMS STK-6)
- Anticoagulation for atrial fibrillation if detected (CMS STK-3)
- Blood glucose monitoring and control (target 140-180 mg/dL)
- Temperature management (treat fever aggressively — hyperthermia worsens outcomes)
- Cardiac monitoring for minimum 24 hours (detect new atrial fibrillation)

### Stroke Mimic Differential
- Hypoglycemia (most common mimic — always check glucose first)
- Todd's paralysis (postictal)
- Hemiplegic migraine
- Conversion disorder
- Brain mass or abscess
- Subdural hematoma

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## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the LKW time clearly documented and used to determine treatment window eligibility?
2. Was the NIHSS scored completely with all 15 items and total documented?
3. Were tPA inclusion criteria and contraindications systematically screened and documented?
4. Was LVO screened for and CTA obtained if indicated?
5. Are door-to-needle times documented and meeting AHA/ASA targets?

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## Quality Audit

- [ ] Last known well (LKW) time documented clearly
- [ ] Point-of-care glucose obtained within 10 minutes
- [ ] Non-contrast CT head obtained within 15 minutes of arrival
- [ ] CT interpreted within 20 minutes for hemorrhage
- [ ] NIHSS scored completely (all 15 items) with total documented
- [ ] tPA inclusion and exclusion criteria systematically screened
- [ ] tPA dose calculated correctly (0.9 mg/kg, max 90 mg)
- [ ] Door-to-needle time documented (target ≤60 min)
- [ ] Blood pressure managed per protocol (pre-tPA: <185/110; post-tPA: <180/105)
- [ ] LVO screening performed (NIHSS threshold, cortical signs)
- [ ] CTA obtained if LVO suspected
- [ ] Post-tPA neuro checks scheduled at appropriate intervals
- [ ] Dysphagia screening ordered before oral intake
- [ ] DVT prophylaxis and antithrombotic therapy ordered per CMS core measures
- [ ] Stroke etiology workup initiated (echo, carotid imaging, telemetry)

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## Guidelines

1. Treat time as the single most important variable — every 15-minute reduction in door-to-needle time is associated with measurably better outcomes; do not wait for labs (except glucose and CT) before tPA decision.
2. Hypoglycemia is the most common stroke mimic and the most easily correctable — always obtain point-of-care glucose before any other intervention.
3. Blood pressure must be below 185/110 before tPA administration — use IV labetalol (10-20 mg over 1-2 min) or nicardipine infusion (5 mg/hr, titrate by 2.5 mg/hr every 5-15 min, max 15 mg/hr).
4. Do not delay tPA for lab results unless there is clinical suspicion of coagulopathy or thrombocytopenia — the only mandatory pre-tPA result is glucose and non-contrast CT.
5. NIHSS must be performed by a trained and certified scorer — self-assessment e-learning modules are available through the AHA and must be renewed annually.
6. For patients on DOACs, check anti-Xa level if available; if the last dose was >48 hours ago and renal function is normal, tPA may be considered.
7. Posterior circulation strokes (basilar occlusion) may present with vertigo, diplopia, dysarthria, and ataxia rather than hemiparesis — maintain high suspicion and obtain CTA.
8. Always document the informed consent discussion (or reason consent was waived — e.g., aphasia, altered mental status with no proxy available in time-critical window) before tPA administration.