Ischemic Stroke

The immediate objective is to determine whether the patient has a disabling acute ischemic deficit, exclude intracranial hemorrhage and important mimics, establish time last known well, and identify eligibility for IV thrombolysis and thrombectomy. Use the NIHSS to quantify severity, communicate deficits, and support triage, but do not use a low NIHSS alone to dismiss potentially disabling deficits or large-vessel occlusion.BMJ+1BMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke | Journal of NeuroInterventional SurgeryAHA JournalsGuidelines for the Early Management of Adults With Ischemic Stroke

Perform noncontrast head CT or MRI before specific acute reperfusion therapy. In most U.S. emergency pathways, noncontrast CT provides the essential first imaging information: exclude hemorrhage and assess early ischemic change. Obtain glucose immediately because hypoglycemia can mimic stroke; obtain CBC, coagulation studies, renal function, ECG, and cardiac evaluation in parallel, but do not await coagulation or platelet results before thrombolysis unless anticoagulant exposure, coagulopathy, or thrombocytopenia is suspected.AHA JournalsAHA JournalsGuidelines for the Early Management of Adults With Ischemic Stroke

Intravenous thrombolysis remains the standard acute reperfusion treatment when administered early. Alteplase has established benefit when given within 4.5 hours of onset, with treatment effect diminishing as time to treatment increases.BMJ+1BMJIschemic stroke - Symptoms, diagnosis and treatment | BMJ Best Practice USBMJRevolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy | Practical Neurology The supplied older AHA/ASA guideline describes alteplase 0.9 mg/kg IV, maximum 90 mg, with 10% given as a bolus over 1 minute and the remainder infused over 60 minutes.AHA JournalsAHA JournalsGuidelines for the Early Management of Adults With Ischemic Stroke This dose is historical guidance within the supplied evidence; clinicians should verify against current institutional protocol and current AHA/ASA guidance.

Tenecteplase 0.25 mg/kg IV push was noninferior to standard-dose alteplase in acute ischemic stroke within 4.5 hours in the cited stroke guideline update, including anterior-circulation large-vessel occlusion patients intended for thrombectomy; symptomatic intracranial hemorrhage was similar, and reperfusion outcomes may be better in that bridging setting.BMJBMJChinese Stroke Association guidelines for clinical management of ischaemic cerebrovascular diseases: executive summary and 2023 update | Stroke and Vascular Neurology Practice recommendations and regulatory details should be confirmed locally because the cited source is not a U.S. guideline.

Mechanical thrombectomy is standard of care for selected large-vessel occlusion stroke. In pooled randomized trials of anterior-circulation large-vessel occlusion treated within 6 hours, thrombectomy plus best medical management achieved functional independence at 90 days in 47.6% versus 30.9% with medical management alone, with 154 additional independent patients per 1,000 treated.BMJBMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke | Journal of NeuroInterventional Surgery

Admit patients to a dedicated stroke unit; specialized stroke-unit care improves survival and functional outcome.BMJ+1BMJIschemic stroke - Symptoms, diagnosis and treatment | BMJ Best Practice USAHA JournalsGuidelines for the Early Management of Adults With Ischemic Stroke After IV thrombolysis, perform frequent neurologic and blood-pressure assessments, avoid unnecessary invasive tubes during the first 24 hours, and obtain follow-up brain imaging at 24 hours before starting antiplatelet or anticoagulant therapy according to the cited AHA/ASA protocol.AHA JournalsAHA JournalsGuidelines for the Early Management of Adults With Ischemic Stroke

Monitor for hemorrhagic transformation, cerebral edema, dysphagia, aspiration, arrhythmia, fever, glucose abnormalities, and venous thromboembolism. Screen swallowing before oral intake. Treat hypoglycemia promptly, avoid hypoxemia, identify and treat fever sources, and use cardiac monitoring during the first 24 hours to detect atrial fibrillation and other clinically significant arrhythmias.AHA JournalsAHA JournalsGuidelines for the Early Management of Adults With Ischemic Stroke

Routine urgent anticoagulation to prevent early recurrence or neurologic worsening is not recommended in acute ischemic stroke because bleeding risk offsets benefit in the cited evidence.AHA JournalsAHA JournalsGuidelines for the Early Management of Adults With Ischemic Stroke Aspirin was recommended within 24 to 48 hours after stroke onset in the older AHA/ASA guideline, but not within 24 hours of thrombolysis.AHA JournalsAHA JournalsGuidelines for the Early Management of Adults With Ischemic Stroke Current antithrombotic timing and selection should be verified against contemporary guidance, especially after thrombectomy or hemorrhagic transformation.

Once reperfusion decisions are complete, determine vascular and cardiac mechanisms because secondary prevention is mechanism-dependent. Vascular imaging identifies intracranial and extracranial occlusive disease and access-relevant anatomy; echocardiography and rhythm assessment assess cardioembolic sources. The cited ischemic cerebrovascular disease guideline depicts a cryptogenic-stroke pathway incorporating CTA/MRA, transcranial Doppler, transthoracic or transesophageal echocardiography, and selected catheter angiography or CSF studies when indicated.BMJBMJChinese Stroke Association guidelines for clinical management of ischaemic cerebrovascular diseases: executive summary and 2023 update | Stroke and Vascular Neurology

For noncardioembolic minor ischemic stroke or high-risk TIA, short-term dual antiplatelet therapy is an evidence-based strategy in contemporary stroke care, but the supplied U.S. search material does not provide current U.S. agent selection, dose, or duration. Avoid extrapolating the cited Chinese guideline's genotype-directed ticagrelor regimen into U.S. routine care without confirming current U.S. recommendations.BMJBMJChinese Stroke Association guidelines for clinical management of ischaemic cerebrovascular diseases: executive summary and 2023 update | Stroke and Vascular Neurology

For atrial fibrillation or another cardioembolic source, long-term oral anticoagulation selection must account for renal function, interactions, valve status, and bleeding risk. Direct oral anticoagulants have lower intracranial hemorrhage risk than warfarin in major nonvalvular AF trials, but severe renal impairment and mechanical valves require different approaches; trial populations excluded severe renal impairment, and dabigatran performed poorly in mechanical heart valves.jacc+1jaccPractical Management of Anticoagulation in Patients With Atrial FibrillationjaccAtrial Fibrillation and Thromboembolism in Patients With Chronic Kidney Disease

Evidence for thrombectomy is most mature in anterior-circulation large-vessel occlusion. The supplied guideline identifies ongoing uncertainty regarding very low NIHSS scores, extensive infarct core, M2 occlusion, acute tandem cervical carotid lesions, optimal anesthesia, and post-thrombectomy blood-pressure targets.BMJBMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke | Journal of NeuroInterventional Surgery

In late-window stroke, strict imaging selection improves certainty of benefit, but it also limits generalizability. DAWN and DEFUSE-3 criteria were derived from narrowly selected populations using advanced imaging; patients outside those criteria require expert multidisciplinary review and adherence to current local protocols.BMJBMJEuropean Stroke Organisation (ESO) - European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke | Journal of NeuroInterventional Surgery

Older sources in the search results contain historical treatment thresholds and alteplase protocols. Because the search set also identifies a 2026 AHA/ASA acute ischemic stroke guideline but does not provide its full recommendations, clinicians should verify current U.S. guidance and institutional protocols before implementing treatment details.BMJ+2BMJIschemic stroke - Symptoms, diagnosis and treatment | BMJ Best Practice USAHA Journals2026 Guideline for the Early Management of Patients With ...AHA Journals2026 Acute Ischemic Stroke Guidelines