Ischemic CVA


Last known normal:
Baseline pt was neurologically intact.
Not candidate for tPA (LKN > 4.5 hours)
s/p tPA (LKN < 4.5 hours) +/- Thrombectomy (LVO)
-- Sx:
☐ Alert / Lethargic / Comatose
☐ following Command
☐ Left upper extremity hemiparesis/hemiplegia: Yes / No*
☐ Right upper extremity hemiparesis/hemiplegia: Yes / No
☐ Left lower extremity hemiparesis/hemiplegia: Yes / No
☐ Right lower extremity hemiparesis/hemiplegia: Yes / No
☐ Facial asymmetry (UMN pattern): Left / Right / None
☐ Left hemisensory deficit (light touch/pain): Yes / No
☐ Right hemisensory deficit (light touch/pain): Yes / No
☐ Left homonymous hemianopsia: Yes / No
☐ Right homonymous hemianopsia: Yes / No
☐ Aphasia (understanding or producing): Present / Absent
☐ Dysarthria (articulation): Present / Absent
☐ Left / Right / Absent Hemispatial neglect
☐ Left-sided limb ataxia (dysmetria): Yes / No
☐ Right-sided limb ataxia (dysmetria): Yes / No
Cranial Nerves
☐ Facial nerve (CN VII) weakness: Left / Right / None
☐ Dysphagia (CN IX/X): Present / Absent
☐ Dysphonia/hoarseness (CN X): Present / Absent
☐ Tongue deviation (CN XII): Left / Right / None

associated symptoms: Headache, nausea/vomiting, and altered mental status (with palpitations suggesting a cardioembolic source such as atrial fibrillation).

with No seizure activity, no syncope or loss of consciousness, no head trauma, no fever or signs of infection, no hypoglycemia, and no recent toxin or drug exposure.

-- Vitals: (BP < 185 to give tPA)
-- W/U: CBC, CMP, Coags, Lipid panel, A1c CT head --- CTA head/Neck --- EKG---
-- PE:

-- RF : HTN,HLD,Smoking,DM,High BMI, Afib, HF, prosthetic valves, PFO,Endocarditis,PAD
-- Meds: last AC --
-- recent surgeries, history of bleeding (severe GIB or ICH),

DDX:

  • MCA stroke:Patient presents with left/right contralateral hemiparesis and hemisensory loss (face/arm > leg) with left/right homonymous hemianopsia; if left (dominant) hemisphere → aphasia, if right (nondominant) → hemispatial neglect.

  • ACA stroke:Patient presents with left/right contralateral lower extremity > upper extremity weakness and sensory loss, with possible abulia and urinary incontinence.

  • PCA stroke:Patient presents with left/right homonymous hemianopsia ± macular sparing; if left (dominant) → alexia without agraphia, if right → visual agnosia.

  • Brainstem (basilar) stroke:Patient presents with quadriplegia, dysarthria, dysphagia, and altered level of consciousness, concerning for locked-in syndrome.

  • PICA (lateral medullary) stroke:Patient presents with ipsilateral facial pain and temperature loss with contralateral body pain and temperature loss, ataxia, dysphagia, hoarseness, and ipsilateral Horner syndrome.

  • AICA stroke:Patient presents with ipsilateral facial paralysis, decreased lacrimation and salivation, loss of taste (anterior 2/3), vertigo, ataxia, and hearing loss.

Plan
-- Neurology consulted
-- ? s/p tPA (LKN < 4.5 hours), +/- Thrombectomy <6h (all LVO); <24h (selected LVO: ICA/MCA/BA)
-- repete CTH in 24‑hour after thrombolysis/thrombectomy before aspirin
-- permissive hypertension SBP < 220 if no t-PA
-- SBP < 185 mmHg if Thrombolysis (t-PA)
-- SBP 140-180 Following thrombectomy
-- PRN labetalol + nicardipine gtt  as needed
-- pressers to keep SBP above 140 for proper perfusion
-- Start aspirin 325->-81 daily ( after 24 hr if thrombolysis or thrombectomy + repeat CT first)
-- High intensity statin (atorvastatin 80 mg or rosuvastatin 20 mg daily)
-- keep euvolemic IVF as needed , Avoid hypoosmolar (e.g. D5W, D51/2NS)
-- keep Normoglycemia 140-180
-- Keep Euthermic, Tylenol 1000 mg q6h PRN, Use external cooling PRN
-- Delay DVT prophylaxis for 24 hours in thrombolysis or thrombectomy pt (SCDs) LMWH after
-- Monitor for herniation due to worsening cerebral edema or hemorrhagic conversion, Low threshold for stat CTH and contact neurology/neurosurgery
-- Neuro checks q2hrs->q4 hrs
-- monitor I/Os
-- Keep on Tele
-- SpO2 goal > 92%
-- PT/OT/SLP to treat and evaluate  (within 24-48 hours)
-- Aspiration precautions: NPO until evaluated by Speech
-- follow up A1c and lipid panel (A1c goal <7.0% o LDL goal <70)
-- trend CBC,BMP
-- consider TTE with bobble to assess for intracardiac thrombus/PFO
-- manage nausea/vomiting as needed
-- Head of bed 30°

Note
-- Urgent carotid revascularization if >70% ICA stenosis On CT

tPA Contraindications (Clean + With Values)

ABSOLUTE

  • ❌ Hemorrhage on CT

  • ❌ Prior intracranial hemorrhage

  • ❌ Ischemic stroke within 3 months

  • ❌ Intracranial neoplasm / AVM / aneurysm

  • ❌ Suspected aortic dissection

  • ❌ Active internal bleeding

  • ❌ Platelets <100,000/mm³

  • ❌ INR >1.7

  • ❌ PT >15 sec(or above lab normal)

  • ❌ aPTT >40 sec(or above lab normal, esp if on heparin)

  • ❌ Therapeutic LMWH within 24 hrs

  • ❌ Heparin within 48 hrs + elevated aPTT

  • ❌ DOAC with recent use + abnormal labs

  • ❌ SBP ≥185 or DBP ≥110 despite treatment
    RELATIVE

  • ⚠️ >4.5 hours from symptom onset

  • ⚠️ DOAC use within 48 hrs

  • ⚠️ Pregnancy

  • ⚠️ Recent surgery/trauma (<14 days)

  • ⚠️ GI/GU bleed (<21 days)

  • ⚠️ Seizure at onset

  • ⚠️ Large infarct on imaging

  • ☐ CBC (Hgb, Platelets <100k?)

  • ☐ CMP/BMP (Na, Cr, glucose)

  • ☐ Coags: PT/INR, aPTT

  • ☐ HbA1c

  • ☐ Lipid panel

  • ☐ Type & screen (if large stroke / possible intervention)

  • ☐ STAT Non-contrast CT head

  • ☐ CTA head & neck (evaluate LVO)

  • ☐ CT perfusion (if thrombectomy window extended)

  • ☐ MRI brain (DWI) (if diagnosis unclear or later)

  • ☐ EKG (look for Afib)

  • ☐ Telemetry monitoring

  • ☐r TTE ± bubble study (PFO / thrombus)

  • ☐Nurology conult

  • ☐ tPA (alteplase) if eligible

  • ☐ Mechanical thrombectomy consult (LVO, <24h selected)

  • ☐ Aspirin 325 mg load → 81 mg daily WAIT 24 hrs if tPA/thrombectomy + repeat CT first

  • ☐ Atorvastatin 80 mg OR Rosuvastatin 20 mg

    • ☐ Labetalol PRN

  • ☐ Nicardipine gtt PRN
    Targets:

  • ☐ <185/110 if tPA candidate

  • ☐ <220/120 if no tPA (permissive HTN)

  • ☐ 140–180 post-thrombectomy

  • ☐ SSI Maintain 140–180

  • ☐ Acetaminophen PRN

  • SCDs immediately

  • LMWH after 24 hrs (if tPA given)

    • ☐ Neuro checks q2h → q4h

  • ☐ Strict I/O

  • ☐ Continuous telemetry

  • ☐ SpO₂ goal >92%

  • ☐ Head of bed 30°

    • ☐ NPO until swallow eval

  • ☐ SLP consult

  • ☐ Aspiration precautions

  • PT/OT consult (within 24–48h)

  • trend CBC, BMP**