When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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EmergentNeurology

Acute Ischemic Stroke

Time is brain. Every minute of ischemia = ~1.9 million neurons lost. Know the tPA window, thrombectomy criteria, NIHSS-driven antiplatelet choice, and BP targets cold. You will not have time to look them up mid-code stroke.

🔍 Overview

Time Windows

Intervention	Window	Key Criteria	Trial
IV alteplase (tPA) 1ST LINE	≤ 4.5 hours from last known well (LKW)	0.9 mg/kg IV (max 90 mg). 10% bolus over 1 min, 90% infusion over 60 min. No anticoagulants or antiplatelets × 24h post.	NINDS, 1995 ECASS III, 2008
IV tenecteplase EMERGING FIRST-LINE	≤ 4.5 hours	0.25 mg/kg IV single bolus (no infusion, push-and-go). Easier, faster, saves ~5 min vs alteplase.	AcT, 2022: tenecteplase non-inferior to alteplase. Now preferred at many stroke centers.
Mechanical thrombectomy LVO	≤ 24 hours (with perfusion imaging 6–24h)	Large vessel occlusion (LVO): ICA, M1, M1-equivalent, basilar. NIHSS ≥ 6. ≤ 6h: CTA showing LVO is sufficient MR CLEAN, 2015 ESCAPE, 2015. 6–24h: requires perfusion mismatch on CT perfusion or MR-DWI DAWN, 2018 DEFUSE 3, 2018.	Multiple trials, NNT ~3–5 for LVO

tPA and thrombectomy are NOT mutually exclusive. If LVO suspected → give tPA AND activate thrombectomy team simultaneously. Do not wait for tPA to work before calling interventional.

NIHSS Severity Bands, Drives Antiplatelet Choice

NIHSS	Severity	Antiplatelet Strategy (24h post-tPA / day 1 if no tPA)
0–3	Minor stroke / TIA (or high-risk TIA, ABCD² ≥ 4)	DAPT × 21 days: ASA 325 mg load → 81 mg + clopidogrel 300–600 mg load → 75 mg daily. Then ASA alone long-term. CHANCE, 2013 POINT, 2018
4–5	Mild-moderate (non-cardioembolic)	ASA alone, or consider ticagrelor 90 mg BID + ASA × 30d (NIHSS ≤ 5) THALES, 2020
≥ 6	Moderate-severe / LVO	ASA 325 mg load → 81 mg. No DAPT, unproven benefit + hemorrhagic conversion risk with large infarct.

Key rule: DAPT is for minor stroke (NIHSS ≤ 3) or high-risk TIA (ABCD² ≥ 4) only. Starting DAPT in moderate-severe stroke does NOT improve outcomes and increases bleeding. Don't reflexively pair ASA + clopidogrel in every stroke admission.

tPA Contraindications

Active internal bleeding or known bleeding diathesis
History of ICH (any time), absolute
Ischemic stroke or head/spine trauma within 3 months
Intracranial neoplasm, AVM, or aneurysm
Platelets < 100,000, INR > 1.7, aPTT elevated, PT > 15
BP > 185/110 despite treatment (must lower before tPA)
Glucose < 50 (correct first, hypoglycemia is a stroke mimic)
On DOAC within 48h (or detectable anti-Xa level) or therapeutic LMWH within 24h
Recent major surgery within 14 days or intracranial/spinal surgery within 3 months
GI or GU bleed within 21 days
Arterial puncture at non-compressible site within 7 days
Suspected infective endocarditis (hemorrhagic transformation + septic embolus risk)
Suspected aortic dissection

🚨 Management

Acute Stroke Protocol

0 min -Door

Activate stroke code. ABC. Finger stick glucose (correct if < 60). NIHSS score. Two large-bore IVs. Labs: CBC, BMP, coags, troponin, type & screen.

≤ 20 min -CT

Non-contrast CT head -rule out hemorrhage. CTA head and neck -identify LVO for thrombectomy. CT perfusion if 6–24h window.

≤ 45 min -tPA

If eligible: alteplase 0.9 mg/kg IV (max 90 mg) or tenecteplase 0.25 mg/kg bolus. Door-to-needle target < 60 min. Lower BP to < 185/110 before tPA (labetalol 10–20 mg IV or nicardipine drip).

Thrombectomy

If LVO on CTA → activate interventional neuroradiology. Do not delay tPA for thrombectomy. Give tPA, then go to angio suite. Door-to-puncture target < 90 min.

BP Targets

Scenario	Target	Agents
Pre-tPA	< 185/110	Labetalol 10–20 mg IV, nicardipine 5–15 mg/hr
Post-tPA (24h)	< 180/105	Same agents. Avoid antiplatelets/anticoagulants × 24h.
No tPA given, not for thrombectomy	Permissive HTN < 220/120	Only treat if > 220/120, end-organ damage, or aortic dissection.
Post-thrombectomy	< 140/90 (some use < 160/90)	Tighter control to prevent reperfusion hemorrhage.

Permissive hypertension in stroke maintains perfusion through collaterals. Dropping BP too aggressively in the penumbra zone worsens ischemia. Only lower BP if giving tPA, > 220/120, or specific indications.

Post-thrombectomy BP update: Recent trials (BP-TARGET, 2021, ENCHANTED2/MT, 2022) show intensive BP control < 130 after successful thrombectomy may be HARMFUL. Trend is now toward individualized moderate control (≤ 180/105), not aggressive lowering.

Post-tPA Management (First 24h)

ICU or stroke unit admission
Neuro checks q15 min × 2h → q30 min × 6h → q1h × 16h, catches hemorrhagic conversion early
BP monitoring on same schedule; keep < 180/105
NO antiplatelets, NO anticoagulants × 24h
Avoid central line, arterial line, bladder catheter, NGT × 24h unless essential, bleeding risk at puncture sites
NPO until dysphagia screen passes (formal SLP eval if concerning)
Head of bed: flat if tolerated early (perfusion); 30° if aspiration risk
Repeat CT head at 24h before starting antiplatelets/anticoagulants, rule out asymptomatic hemorrhagic conversion
Dysphagia screen (bedside water swallow) before any PO. Failed → NPO, SLP consult, NGT for meds

Symptomatic ICH After tPA, Reversal

Any acute neuro decline, new HA, vomiting, or BP spike post-tPA = hemorrhagic conversion until proven otherwise. Stop tPA infusion, stat CT head.

Stop tPA infusion immediately
Cryoprecipitate 10 units IV (target fibrinogen > 150–200 mg/dL), the primary reversal agent. NOT FFP (too slow)
Tranexamic acid (TXA) 1 g IV over 10 min as antifibrinolytic adjunct
Platelets if plt < 100K
Aggressive BP control, target SBP < 140 with nicardipine drip INTERACT2, 2013
Stat neurosurgery consult, possible hemicraniectomy (massive MCA + midline shift < 48h, age < 60) or posterior fossa decompression

📋 Clinical Example, Acute Ischemic Stroke: tPA + Thrombectomy Decision

Patient: 72M with a-fib (not on anticoagulation), last known well 2 hours ago, found with right-sided weakness and aphasia. NIHSS 14. BP 196/104, glucose 112, INR 1.1, plts 240K.

Decision tree (door-to-needle ≤ 60 min):

0–10 min: Stroke code activated. Fingerstick glucose 112 (mimic excluded). NIHSS 14. Two large-bore IVs. Labs sent.
10–20 min: Non-con CT, no hemorrhage. CTA, left M1 occlusion. CT perfusion, ischemic core 18 mL, penumbra 72 mL (large mismatch).
20–30 min: BP 196/104 → labetalol 20 mg IV, then nicardipine drip → BP 178/94 (below 185/110 threshold).
30–45 min: Alteplase 0.9 mg/kg IV (weight 80 kg → 72 mg; 7.2 mg bolus, 64.8 mg over 60 min). Simultaneously activate thrombectomy team.
45–90 min: To angio suite during tPA infusion. Mechanical thrombectomy → TICI 2b recanalization at 75 min from door.
Post: NICU admission. Neuro checks q15 min × 2h. BP < 180/105. No antiplatelets × 24h. Repeat CT at 24h → no hemorrhagic conversion → start ASA 325 mg load. NIHSS was 14 (> 3) → NO DAPT, ASA alone. Plan: apixaban 5 mg BID starting day 6 for AF secondary prevention.

Teaching point: tPA is a bridge to thrombectomy, give both when LVO is present. Never delay tPA for CTA. Post-stroke antiplatelet choice is driven by NIHSS: DAPT only for NIHSS ≤ 3.

📋 On Rounds

Pimp Questions

What extended the thrombectomy window from 6h to 24h?

DAWN, 2018 and DEFUSE 3, 2018. Both showed that patients with clinical-imaging mismatch (large clinical deficit but small infarct core on perfusion imaging) benefit from thrombectomy up to 24h. DAWN used clinical-core mismatch; DEFUSE 3 used perfusion-core mismatch. The key concept: it's not about time -it's about salvageable penumbra.

Why check glucose before tPA?

Hypoglycemia is a stroke mimic -it can cause focal neurological deficits identical to stroke (hemiparesis, aphasia, altered consciousness). Giving tPA to a hypoglycemic patient exposes them to major bleeding risk for no benefit. A finger stick glucose takes 10 seconds and is the fastest way to rule out this mimic. Correct glucose < 60, then reassess symptoms before proceeding.

What is the extended window for thrombectomy and what imaging do you need?

Standard tPA window: 0-4.5 hours. Thrombectomy for LVO: up to 24 hours with favorable imaging. DAWN, 2018: 6-24h window if clinical deficit is disproportionate to infarct size on perfusion imaging ("mismatch"). DEFUSE-3, 2018: 6-16h window with perfusion mismatch. Imaging required for extended window: CTA (confirms LVO -M1 MCA, ICA, basilar) + CT perfusion or MRI DWI/perfusion (shows salvageable tissue = penumbra).

What are the absolute contraindications to IV tPA?

Absolute contraindications (within 4.5h window): (1) Active internal bleeding or bleeding diathesis, (2) History of ICH (any time), (3) Ischemic stroke or head/spine trauma within 3 months, (4) Intracranial neoplasm, AVM, or aneurysm, (5) Platelets < 100K / INR > 1.7 / aPTT elevated / DOAC within 48h, (6) SBP > 185 or DBP > 110 not controlled despite treatment, (7) Recent major surgery within 14 days or intracranial/spinal surgery within 3 months, (8) GI/GU bleed within 21 days, (9) Arterial puncture at non-compressible site within 7 days, (10) Suspected infective endocarditis or aortic dissection. Glucose < 50 must be corrected first (stroke mimic).

Does every stroke patient get aspirin + clopidogrel?

No, NIHSS drives the choice. Dual antiplatelet (ASA + clopidogrel × 21 days) is only indicated for minor stroke (NIHSS ≤ 3) or high-risk TIA (ABCD² ≥ 4), started within 24h CHANCE, 2013 POINT, 2018. For moderate-severe stroke (NIHSS ≥ 6) or LVO, DAPT increases bleeding without benefit, give ASA alone. THALES, 2020 added ticagrelor + ASA × 30d as alternative for NIHSS ≤ 5 non-cardioembolic. Don't reflexively pair ASA + clopidogrel in every stroke admission.

Tenecteplase or alteplase, which is better?

Non-inferior, and tenecteplase is winning on workflow. AcT, 2022 showed tenecteplase 0.25 mg/kg IV single bolus non-inferior to alteplase 0.9 mg/kg infusion for functional outcome, with similar sICH rates. Tenecteplase advantages: single 5-second push (vs 1-hour infusion), easier transfer to thrombectomy suite, saves ~5 min door-to-needle, same cost. Many stroke centers have switched tenecteplase-first. AHA/ASA lists both as acceptable.

Why permissive hypertension in acute stroke?

The penumbra (viable but ischemic brain around the core infarct) survives on collateral flow, which is passive and pressure-dependent. Dropping BP collapses collaterals → penumbra converts to infarct → worse outcome. AHA guideline: don't treat BP unless > 220/120 in ischemic stroke without tPA. Exceptions: tPA given (must be < 185/110 → < 180/105), aortic dissection, active MI, HF, hypertensive encephalopathy.

Patient on apixaban had last dose 36h ago, can they get tPA?

No, DOACs within 48h are a contraindication to tPA unless an anti-Xa level is undetectable (often unavailable in real time). Alternative: mechanical thrombectomy if LVO is present (tPA contraindications don't preclude thrombectomy). Andexanet alfa reverses apixaban/rivaroxaban but prolongs stroke code timeline too much to be practical as pre-tPA bridge. Stick to thrombectomy in DOAC patients with LVO.

Clinical Examples

📋 Case 1, Large Vessel Occlusion within tPA Window

Patient: 73F with Afib (not on anticoagulation), found by husband with left-sided weakness and slurred speech. Last known well 2 hours ago.

Key findings: BP 178/96, HR 88 (irregular), NIHSS 18 (R gaze preference, left hemiplegia, left hemineglect, dysarthria). CT head: no hemorrhage. CTA: right MCA M1 occlusion. CT perfusion: large penumbra with small core (< 30 mL).

Management:

IV alteplase 0.9 mg/kg (10% bolus, 90% over 60 min). Door-to-needle target ≤ 60 min NINDS, 1995
BP must be < 185/110 BEFORE tPA. Use IV labetalol or nicardipine drip. After tPA: maintain < 180/105 x 24h
Thrombectomy: LVO + NIHSS ≥ 6 + small core = candidate up to 24h DAWN, 2018
tPA is a bridge to thrombectomy. Do NOT delay tPA for CTA

Teaching point: tPA is a bridge, not a destination. If LVO is identified, proceed to thrombectomy regardless of tPA response. Never delay tPA to obtain CTA.

📋 Case 2, Minor Stroke, DAPT Candidate

Patient: 62M with HTN, presents with 30 min of mild right facial droop and word-finding difficulty. Symptoms now resolved. NIHSS 1 (mild dysarthria only). LKW 90 min ago. BP 158/92. Glucose 104.

Key findings: CT head: no hemorrhage. CTA: 60% left MCA stenosis, no occlusion. MRI DWI: punctate left M2 infarct. Within tPA window but NIHSS = 1 → marginal tPA benefit vs bleeding risk. Rapid resolution suggests TIA-like physiology.

Management:

Hold tPA, mild deficit with rapid improvement, low NIHSS = discuss with attending; marginal benefit vs real bleeding risk
Start DAPT: ASA 325 mg load → 81 mg daily + clopidogrel 300 mg load → 75 mg daily × 21 days, then ASA alone CHANCE, 2013 POINT, 2018
High-intensity statin: atorvastatin 80 mg daily SPARCL, 2006
BP goal: add lisinopril, target < 130/80 long-term
Etiology workup: carotid Doppler, echo, AF monitoring (Holter or Reveal LINQ if cryptogenic)

Teaching point: Minor stroke / high-risk TIA is the DAPT niche. NIHSS ≤ 3 within 24h → ASA + clopidogrel × 21 days. This is CHANCE, 2013 / POINT, 2018 territory. Don't extend DAPT beyond 21 days (bleeding rises).

📋 Case 3, Wake-Up Stroke with Unknown Onset

Patient: 65M found by wife at 6 AM with right-sided weakness and aphasia. Was normal at bedtime (11 PM). Last known well ~7 hours ago.

Key findings: NIHSS 14 (global aphasia, right hemiplegia). CT head: no hemorrhage. MRI DWI: acute left MCA infarct. FLAIR: no corresponding signal change (DWI-FLAIR mismatch = stroke likely < 4.5h). CTA: left M1 occlusion.

Management:

DWI-FLAIR mismatch suggests onset < 4.5h despite unknown last known well WAKE-UP Trial, 2018
IV alteplase can be given based on WAKE-UP trial criteria (DWI positive, FLAIR negative)
LVO with favorable perfusion: eligible for thrombectomy up to 24h (DAWN/DEFUSE-3 criteria)
If MRI not rapidly available, CT perfusion can identify salvageable penumbra

Teaching point: Wake-up strokes are no longer excluded from thrombolysis. DWI-FLAIR mismatch on MRI can extend the treatment window. Perfusion imaging selects patients based on tissue status, not time alone.

📋 Case 4, Hemorrhagic Conversion After tPA

Patient: 70M received tPA 4 hours ago for acute ischemic stroke (NIHSS 12). Nurse calls: new vomiting, declining consciousness (GCS 14 to 9), new hypertension 210/115.

Key findings: GCS 9, left pupil dilating, right hemiplegia worsening. Consistent with symptomatic intracerebral hemorrhage (sICH) -- most feared tPA complication (~6% incidence).

Management:

Stop tPA infusion immediately. Stat CT head without contrast
Reversal: cryoprecipitate 10 units IV (target fibrinogen > 200 mg/dL). Tranexamic acid 1g IV as adjunct
Aggressive BP control: target SBP < 140 with nicardipine drip INTERACT2, 2013
Stat neurosurgery consult for possible EVD or hemicraniectomy. Reverse coagulopathy before any procedure

Teaching point: Any neurological decline after tPA = hemorrhagic conversion until proven otherwise. Stop tPA, get immediate CT, and give cryoprecipitate (NOT FFP -- too slow). Fibrinogen is the critical target in tPA-related ICH.

📣 Sample Presentation

One-Liner

"Mrs. Taylor is a 73-year-old with Afib (not on anticoagulation) presenting with acute left-sided weakness and aphasia, NIHSS 18, last known well 2 hours ago. CT head negative for hemorrhage. CTA shows right MCA M1 occlusion."

Key Points to Cover on Rounds

Acute ischemic stroke, right MCA LVO, NIHSS 18. CT negative for hemorrhage. Alteplase 0.9 mg/kg administered at 2.5h. Thrombectomy team activated → TICI 2b recanalization. Post-procedure NIHSS 8 (improving). BP target < 180/105 × 24h post-tPA. Repeat CT at 24h: no hemorrhagic conversion. Antiplatelet: ASA 325 mg load → 81 mg (NIHSS 18 → no DAPT per CHANCE/POINT, which require NIHSS ≤ 3). Dysphagia screen: failed → NPO, NGT. Etiology: AF, never anticoagulated. Plan: apixaban 5 mg BID starting day 6 (moderate infarct per 1-3-6-12 rule). Atorvastatin 80 mg. PT/OT/SLP. Secondary prevention (BP < 130/80, lipids, AF).

Monitoring (Post-tPA / Post-Thrombectomy)

Parameter	Frequency	Target / Action
Neuro checks (NIHSS-guided)	q15 min × 2h → q30 min × 6h → q1h × 16h (then q4h × 24h)	Any decline = stat CT to rule out hemorrhagic conversion
Blood pressure	Same schedule as neuro checks × 24h	< 180/105 post-tPA. < 185/110 pre-tPA. Treat with labetalol or nicardipine.
Fingerstick glucose	q1–4h initially	Target 140–180 mg/dL. Avoid hypoglycemia (mimic) and severe hyperglycemia (worsens infarct).
Temperature	q4h	Fever > 38°C worsens outcome, acetaminophen PRN, find source, treat aggressively.
Telemetry	Continuous × 24h minimum	Catch occult AF (major etiology). Prolonged monitoring (Holter, Reveal LINQ) if cryptogenic.
Dysphagia screen	Before ANY PO intake	Failed → NPO, SLP eval, NGT for meds/nutrition. Aspiration pneumonia is a top post-stroke killer.
Repeat CT head	At 24h post-tPA (before antiplatelets)	Rule out asymptomatic hemorrhagic conversion before starting ASA ± clopidogrel
DVT prophylaxis	From admission	Mechanical immediately; LMWH (enoxaparin 40 mg SC daily) after 24h if repeat CT clear

🧪 Workup

Rapid Workup, Everything Happens in Parallel

Stroke code = parallel processing. Labs, CT, NIHSS, and IV access happen simultaneously. Nobody waits for anyone. Door-to-needle ≤ 60 min.

Focused History (from patient, family, EMS, bystanders)

Last known well (LKW), NOT symptom-discovery time. "When was the patient definitely at their neurologic baseline?" This drives the tPA window.
Wake-up stroke? LKW = bedtime. Consider MRI DWI-FLAIR mismatch for thrombolysis WAKE-UP, 2018.
Anticoagulants or antiplatelets: warfarin (check INR), DOACs (last dose < 48h = contraindication), LMWH, DAPT
Prior stroke / TIA, ICH, head trauma, seizures, migraines (mimics)
Recent surgery (within 14 days major; 3 months intracranial/spinal), recent GI/GU bleed (within 21 days), recent arterial puncture (within 7 days)
Medical history: AF, HTN, DM, HLD, CAD, PFO, hypercoagulable states, pregnancy, recent illness (endocarditis risk)
Red flags: Thunderclap HA (SAH), neck pain after trauma (dissection), cocaine/sympathomimetic use, recent febrile illness (endocarditis)

NIHSS, Score Every Patient

NIHSS drives thrombectomy eligibility (≥ 6), antiplatelet choice (≤ 3 = DAPT), prognosis, and transfer decisions. Score BEFORE tPA, after tPA, and daily. 11 items, 0–42 scale. → Open interactive NIHSS calculator

NIHSS underscores posterior circulation strokes. A basilar occlusion may score 2–4 despite catastrophic disease. Don't let a low NIHSS talk you out of thrombectomy for a vertebrobasilar LVO, use clinical judgment + CTA.

Imaging (Target ≤ 20 min)

Study	Purpose	Key Findings
Non-contrast CT head FIRST	Rule out hemorrhage, tPA contraindicated if ICH	Early ischemic changes (loss of gray-white differentiation, insular ribbon sign, hyperdense MCA sign). ASPECTS score < 6 = large core → poor thrombectomy candidate.
CTA head & neck ESSENTIAL FOR LVO	Identify LVO (ICA, M1, M1-equivalent, basilar) for thrombectomy triage	Clot visualization. Collateral scoring. Carotid stenosis / dissection. Tandem occlusions. Do NOT delay tPA waiting for CTA.
CT perfusion	Extended-window thrombectomy (6–24h), identify salvageable penumbra	Mismatch: large hypoperfused region + small core = penumbra. RAPID / Olea software auto-quantifies Tmax and CBF.
MRI DWI + FLAIR	Confirm infarct. Wake-up stroke selection.	DWI+/FLAIR− = stroke < 4.5h (even if LKW unknown) → tPA-eligible per WAKE-UP.
Echo (TTE ± TEE)	Etiology workup (post-acute)	LV thrombus, PFO, atrial myxoma, endocarditis. TEE better for LA appendage, aortic arch atheroma, vegetation.
Carotid duplex / CTA neck	Etiology, carotid stenosis	> 70% symptomatic stenosis → CEA (within 2 weeks) or CAS.

Labs

Fingerstick glucose FIRST (10 seconds, hypoglycemia is the #1 stroke mimic). Target > 60 before tPA; 140–180 on admission.
CBC, platelets > 100K required for tPA
BMP, glucose, electrolytes, renal function (for contrast dosing)
PT/INR, aPTT, INR > 1.7 contraindicates tPA
Troponin, co-existing MI is common; may change dispo
Type & screen, in case of hemorrhagic conversion
Pregnancy test (if reproductive age), tPA is not absolutely contraindicated but needs MFM discussion
DOAC level / anti-Xa if on apixaban/rivaroxaban within 48h (often unavailable in real time, default to thrombectomy)
EKG, AF, STEMI, LVH
Tox screen if AMS (sympathomimetic-induced stroke, cocaine)

Stroke Mimics, Rule Out Before tPA

Hypoglycemia, fingerstick glucose. Single most important mimic. Correct and reassess.
Seizure / Todd paralysis, post-ictal focal weakness. History of seizure, tongue-biting, incontinence, confusion clearing.
Migraine with aura, gradual onset, positive phenomena (scintillations), HA follows.
Conversion disorder, non-anatomic distribution, give-way weakness, psych context.
Complex migraine / hemiplegic migraine
Sepsis, toxic-metabolic encephalopathy, hypertensive encephalopathy
Bell's palsy, forehead-sparing is UMN (stroke); no forehead sparing is LMN (Bell's).
Peripheral vertigo, BPPV, vestibular neuritis. HINTS exam to differentiate from central (posterior stroke).

💊 Medications

Thrombolytics

Drug	Dose	Administration	Key Points
Alteplase (Activase, tPA) STANDARD	0.9 mg/kg IV (max 90 mg)	10% as bolus over 1 min, 90% infused over 60 min	Binds fibrin → plasmin → clot lysis. sICH ~6%. Monitor for orolingual angioedema (esp. on ACEi), stop infusion, IV steroid + H1/H2 blockers.
Tenecteplase (TNKase) EMERGING FIRST-LINE	0.25 mg/kg IV bolus (max 25 mg)	Single push, no infusion. Done in 5 seconds.	Genetically modified alteplase, higher fibrin specificity, longer half-life. AcT, 2022 showed non-inferiority. Faster workflow, same safety.

tPA Reversal (Symptomatic ICH)

Agent	Dose	Purpose
Cryoprecipitate 1ST LINE	10 units IV	Fibrinogen replacement, target > 150–200 mg/dL. Works within 30 min. NOT FFP (too slow).
Tranexamic acid (TXA)	1 g IV over 10 min	Antifibrinolytic adjunct. Alternative: aminocaproic acid.
Platelets	1 unit apheresis (if plt < 100K)	Replacement if thrombocytopenic.

Blood Pressure (Pre/Post-tPA)

Drug	Dose	Notes
Labetalol	10–20 mg IV q10 min, max 300 mg	β1/β2/α blocker. First-line. Avoid in severe asthma/COPD, decompensated HF, bradycardia < 50.
Nicardipine	Start 5 mg/hr IV, titrate 2.5 mg/hr q5–15 min, max 15 mg/hr	Dihydropyridine CCB. Smooth titratable infusion. Preferred in reactive airway disease.
Clevidipine	Start 1–2 mg/hr IV, double q90 sec, max 32 mg/hr	Ultra-short half-life (~1 min). Lipid emulsion, avoid in egg/soy allergy, severe HLD.
Hydralazine	10–20 mg IV q4–6h PRN	Rescue option. Unpredictable response + reflex tachycardia. Not first-line in stroke.

Antiplatelets, NIHSS Drives the Choice

Wait 24h post-tPA before starting any antiplatelet. Check repeat CT first, rule out asymptomatic hemorrhagic conversion.

NIHSS	Regimen	Evidence
0–3 (minor stroke) OR high-risk TIA (ABCD² ≥ 4)	DAPT × 21 days: • ASA 325 mg load → 81 mg daily • Clopidogrel 300–600 mg load → 75 mg daily • Then ASA alone long-term	CHANCE, 2013 POINT, 2018
≤ 5 (non-cardioembolic)	Alternative: Ticagrelor 180 mg load → 90 mg BID + ASA × 30 days	THALES, 2020
≥ 6 or LVO	ASA alone, 325 mg load → 81 mg daily. No DAPT.	DAPT increases bleeding without proven benefit in moderate-severe stroke. Large infarct core + DAPT = hemorrhagic conversion risk.

Clopidogrel CYP2C19 non-responders (~30% of East Asians, ~15% of others): consider ticagrelor instead. Genotyping is done at some stroke centers after DAPT failure.

Statin

Drug	Dose	Notes
Atorvastatin HIGH INTENSITY	80 mg PO daily	Start on admission. SPARCL, 2006. LDL goal < 70 mg/dL.
Rosuvastatin HIGH INTENSITY	20–40 mg PO daily	Alternative if atorvastatin intolerance. In Asian patients lower doses may suffice.

Anticoagulation (Cardioembolic Stroke, AF)

Timing rule of thumb ("1-3-6-12 day rule"): start DOAC based on infarct size, TIA (day 1), small stroke (day 3), moderate (day 6), large (day 12). ELAN, 2023 supports earlier start than the traditional rule.

Drug	Dose	When to Start (post-stroke)
Apixaban (Eliquis) PREFERRED	5 mg BID (2.5 mg BID if ≥ 2 of: age ≥ 80, weight ≤ 60 kg, Cr ≥ 1.5)	Typical: day 1–3 for small, day 6–12 for large infarct. ELAN 2023 supports earlier.
Rivaroxaban	20 mg daily (15 mg if CrCl 15–50)	Take with food for bioavailability.
Dabigatran	150 mg BID (110 mg BID if high bleed risk)	Avoid CrCl < 30. Idarucizumab for reversal.
Edoxaban	60 mg daily (30 mg if CrCl 15–50 or weight ≤ 60 kg)	Avoid if CrCl > 95 (reduced efficacy).
Warfarin	Goal INR 2–3	Use if mechanical valve, significant mitral stenosis, antiphospholipid syndrome. Bridge with heparin if INR < 2.

Adjuncts & Supportive

Glucose control: target 140–180 mg/dL. Avoid hypoglycemia (mimic) and severe hyperglycemia (worsens infarct).
Fever: acetaminophen PRN. Fever > 38°C worsens outcome, find source, treat aggressively.
DVT prophylaxis: mechanical compression from admission. Enoxaparin 40 mg SC daily after 24h post-tPA (if no ICH on repeat scan). Avoid heparin gtt in cardioembolic stroke, increases hemorrhagic conversion.
Orolingual angioedema on tPA: stop infusion, IV methylprednisolone 125 mg + diphenhydramine 50 mg + famotidine 20 mg. Epinephrine if airway compromise. Higher risk in ACEi users.

⚡ Summary

Summary

tPA Window

0–4.5h from LKW. Door-to-needle ≤ 60 min. Alteplase 0.9 mg/kg (max 90), 10% bolus, 90% over 1h. OR tenecteplase 0.25 mg/kg single bolus (AcT 2022).

Thrombectomy

LVO (ICA, M1, basilar) up to 24h with favorable perfusion imaging [DAWN, DEFUSE-3]. NIHSS ≥ 6. CTA confirms LVO; CT perfusion guides extended window. Door-to-puncture ≤ 90 min.

NIHSS Drives Antiplatelet

NIHSS ≤ 3: DAPT × 21 days (ASA + clopidogrel) [CHANCE, POINT]. NIHSS ≥ 6: ASA alone. NIHSS ≤ 5 non-cardioembolic: ticagrelor + ASA × 30d alternative [THALES].

BP Management

Pre-tPA: < 185/110. Post-tPA: < 180/105 × 24h. No tPA: permissive HTN, treat only if > 220/120. Post-thrombectomy: individualize; intensive < 130 may be harmful (BP-TARGET, ENCHANTED2/MT).

Reversal (sICH)

Stop tPA. Cryoprecipitate 10 units (fibrinogen) + TXA 1 g IV. NOT FFP, too slow. Aggressive BP < 140. Stat neurosurgery.

Anticoagulation (AF)

Start DOAC based on infarct size: small day 1–3, moderate day 6, large day 12 ("1-3-6-12 rule"). ELAN 2023 supports earlier. Apixaban 5 mg BID preferred.

Dysphagia Screen

Before ANY PO. Failed → NPO, NGT for meds/nutrition. Aspiration pneumonia = leading post-stroke killer.

Statin & Secondary Prevention

Atorvastatin 80 mg daily (SPARCL). LDL < 70. BP < 130/80. Carotid stenosis > 70% → CEA/CAS within 2 weeks. Smoking cessation. Glycemic control.

Stroke Mimics

Hypoglycemia (#1, fingerstick!). Seizure + Todd paralysis. Migraine with aura. Conversion disorder. Sepsis / hypertensive encephalopathy. Bell's palsy (forehead-sparing = UMN = stroke).

📄 One Pager

Neurology · One Pager

Acute Ischemic Stroke

tPA within 4.5h. Thrombectomy for LVO up to 24h with mismatch. Door-to-needle ≤ 60 min. NIHSS drives antiplatelet choice. Dysphagia screen before PO.

🧪 Diagnosis

Acute focal neurologic deficit. Fingerstick glucose FIRST (#1 mimic). Non-con CT (rule out ICH). CTA (identify LVO). CT perfusion (mismatch for extended window). NIHSS, drives severity, thrombectomy (≥ 6), antiplatelet (≤ 3 = DAPT).

🎯 Acute Treatment

≤ 4.5h: alteplase 0.9 mg/kg (max 90) OR tenecteplase 0.25 mg/kg bolus. LVO: thrombectomy up to 24h. BP < 185/110 pre-tPA, < 180/105 post × 24h. No antiplatelet/anticoag × 24h post-tPA.

🛡️ Secondary Prevention (by NIHSS)

NIHSS ≤ 3: DAPT × 21d (ASA + clopidogrel) [CHANCE, 2013, POINT, 2018]. NIHSS ≥ 6: ASA alone. AF → DOAC (apixaban preferred, timing by infarct size, 1-3-6-12 rule). Atorvastatin 80 mg. BP < 130/80. Carotid stenosis > 70% → CEA/CAS.

💊 Key Drugs

Alteplase0.9 mg/kg IV (max 90 mg)

Tenecteplase0.25 mg/kg IV bolus

Labetalol10–20 mg IV q10 min

Nicardipine5–15 mg/hr infusion

ASA325 mg load → 81 mg (after 24h)

Clopidogrel300–600 mg load → 75 mg × 21d (NIHSS ≤ 3)

Atorvastatin80 mg PO daily

Apixaban5 mg BID (AF, timing by infarct size)

⚠️ Pitfalls

Delaying tPA for detailed neuro exam (time is brain)
Not checking fingerstick glucose first (hypoglycemia mimic)
Reflexively starting DAPT in NIHSS > 3 (bleeding risk, no benefit)
Dropping BP too aggressively in untreated stroke (collapses penumbra)
Skipping dysphagia screen before PO (aspiration pneumonia)
FFP instead of cryoprecipitate for tPA-related ICH (too slow)
Missing posterior circulation stroke (NIHSS underscores basilar LVO)
Forgetting DOAC within 48h is a tPA contraindication (go to thrombectomy)

📣 Present on Rounds

One-liner: "[Age, sex] with [risk factors] presenting with [deficit], NIHSS [#], LKW [time]. CT no hemorrhage. [CTA findings]. tPA [given/held]. [Thrombectomy]. Post-procedure NIHSS [#]. Plan: [antiplatelet/anticoag by NIHSS], dysphagia screen, [statin/BP/etiology workup]."