Ischemic stroke - Revision history

Danbot: Strip excess bold

2026-03-22T09:26:28Z

Strip excess bold

Danbot: Major expansion: tPA dosing/contraindications, thrombectomy up to 24h (DAWN/DEFUSE3), tenecteplase, BP targets by scenario, NIHSS, LVO identification, drip-and-ship, HINTS, references with PMIDs

2026-03-21T20:03:27Z

Major expansion: tPA dosing/contraindications, thrombectomy up to 24h (DAWN/DEFUSE3), tenecteplase, BP targets by scenario, NIHSS, LVO identification, drip-and-ship, HINTS, references with PMIDs

Show changes

Danbot: Add MedicationDose SMW entries for labetalol, nicardipine, aspirin; doses verified against AHA/ASA stroke guidelines

2026-03-20T17:40:23Z

Add MedicationDose SMW entries for labetalol, nicardipine, aspirin; doses verified against AHA/ASA stroke guidelines

← Older revision		Revision as of 17:40, 20 March 2026
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	==Disposition==		==Disposition==
	*Admit all acute and subacute ischemic strokes		*Admit all acute and subacute ischemic strokes


			==Medication Dosing==
			===Blood Pressure Management (tPA Candidates)===
			*{{MedicationDose\|drug=Labetalol\|dose=10-20 mg over 1-2 min, may repeat x1\|route=IV\|context=BP control for tPA (goal SBP <185)\|indication=Ischemic stroke\|population=Adult}}
			*{{MedicationDose\|drug=Nicardipine\|dose=5 mg/hr, titrate by 2.5 mg/hr q5-15min\|route=IV drip\|context=BP control for tPA (goal SBP <185)\|indication=Ischemic stroke\|population=Adult\|max_dose=15 mg/hr}}

			===Antiplatelet===
			*{{MedicationDose\|drug=Aspirin\|dose=325 mg\|route=PO\|context=Antiplatelet (within 24-48hr)\|indication=Ischemic stroke\|population=Adult\|notes=Do not give within 24hr of tPA}}

	==See Also==		==See Also==

Rossdonaldson1 at 22:08, 22 October 2025

2025-10-22T22:08:20Z

← Older revision		Revision as of 22:08, 22 October 2025
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	==Background==		==Background==
	[[File:Gehirn, lateral - Lobi + Stammhirn + Cerebellum eng.svg\|thumb\|Sagital view of the brain.]]		[[File:Gehirn, lateral - Lobi + Stammhirn + Cerebellum eng.svg\|thumb\|Sagital view of the brain.]]
			[[File:Circle of Willis en.png\|thumb\|Circulation within the Circle of Willis]]
	[[File:23-Sensory-Homonculus.png\|thumb\|Sensory Homonculus - courtesy AnatomyZone.com]]		[[File:23-Sensory-Homonculus.png\|thumb\|Sensory Homonculus - courtesy AnatomyZone.com]]
	{{Ischemic Stroke Cause}}		{{Ischemic Stroke Cause}}

Rossdonaldson1: /* Background */

2025-10-22T22:03:00Z

Background

← Older revision		Revision as of 22:03, 22 October 2025
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	==Background==		==Background==
			[[File:Gehirn, lateral - Lobi + Stammhirn + Cerebellum eng.svg\|thumb\|Sagital view of the brain.]]
	[[File:23-Sensory-Homonculus.png\|thumb\|Sensory Homonculus - courtesy AnatomyZone.com]]		[[File:23-Sensory-Homonculus.png\|thumb\|Sensory Homonculus - courtesy AnatomyZone.com]]
	{{Ischemic Stroke Cause}}		{{Ischemic Stroke Cause}}

Gbiegun: /* Endovascular Therapy */

2021-07-02T23:36:53Z

Endovascular Therapy

← Older revision		Revision as of 23:36, 2 July 2021
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	**Intervention was conducted within 6 hrs		**Intervention was conducted within 6 hrs
	**Functional independence of 32.6% with endovascular treatment and 19.1% with typical therapy		**Functional independence of 32.6% with endovascular treatment and 19.1% with typical therapy
	*~~Institutional dependent time window~~ for ~~intervention~~		*AHA guidelines say the following patients are eligible for mechanical thrombectomy:
			** 0-6 hours: pre-stroke mRS 01, ICA or M1 occlusion, age > 18, NIHSS > 5, puncture < 6 hours
			** 0-6 hours: May also be reasonable in carefully selected patients with M2 or M3 occlusions
			** 6-16 hours: anterior circulation LVO who meet DAWN or DEFUSE 3 criteria
			** 16-24 hours: anterior circulation LVO who meet DAWN criteria
	*May require careful patient selection based on last known normal, ICA/prox MCA occlusion, and additional diagnostic studies such as CT perfusion study, Rapid [[brain MRI\|MRI]], etc<ref>Thrombectomy For Stroke At 6 To 16 Hours With Selection By Perfusion Imaging Albers, G.W., et al, N Engl J Med 378(8):708, February 22, 2018</ref>		*May require careful patient selection based on last known normal, ICA/prox MCA occlusion, and additional diagnostic studies such as CT perfusion study, Rapid [[brain MRI\|MRI]], etc<ref>Thrombectomy For Stroke At 6 To 16 Hours With Selection By Perfusion Imaging Albers, G.W., et al, N Engl J Med 378(8):708, February 22, 2018</ref>
	*Goal SBP <160 after endovascular therapy <ref>Smith M, Reddy U, Robba C, et al. Acute ischaemic stroke: challenges for the intensivist. Intensive Care Med. 2019</ref>		*Goal SBP <160 after endovascular therapy <ref>Smith M, Reddy U, Robba C, et al. Acute ischaemic stroke: challenges for the intensivist. Intensive Care Med. 2019</ref>

ClaireLewis: /* Non-tPA Candidate */

2019-10-23T13:55:43Z

Non-tPA Candidate

← Older revision		Revision as of 13:55, 23 October 2019
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	**Goal MAP for non-thrombolyzed, MAP < 150, per AHA guidelines<ref>Anton Helman. Emergency Medicine Cases. Episode 17 Part 1: Emergency Stroke Controversies. September 2011. https://emergencymedicinecases.com/episode-17-part-1-emergency-stroke-controversies/</ref>		**Goal MAP for non-thrombolyzed, MAP < 150, per AHA guidelines<ref>Anton Helman. Emergency Medicine Cases. Episode 17 Part 1: Emergency Stroke Controversies. September 2011. https://emergencymedicinecases.com/episode-17-part-1-emergency-stroke-controversies/</ref>
	*[[Aspirin]] 325mg (within 24-48hr)		*[[Aspirin]] 325mg (within 24-48hr)
	**add [[~~clopidogrel~~]] (600 mg ~~loading~~ followed by 75 mg daily for 30-90 days) prevents 15 strokes out of 1000 patients at a cost of 5 additional major noncerebral hemorrhages. <ref>[https://www.jwatch.org/na46776/2018/05/17/clopidogrel-plus-aspirin-has-benefits-tia-or-minor-stroke Journal Watch May 17, 2018 Clopidogrel plus Aspirin Has Benefits for TIA or Minor Stroke]</ref><ref>Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA [https://www.nejm.org/doi/full/10.1056/NEJMoa1800410 N Engl J Med 2018; 379:215-225]</ref>		*[[Clopidogrel]] 600 mg load (followed by 75 mg daily for 30-90 days)
			**prevents 15 strokes out of 1000 patients at a cost of 5 additional major noncerebral hemorrhages. <ref>[https://www.jwatch.org/na46776/2018/05/17/clopidogrel-plus-aspirin-has-benefits-tia-or-minor-stroke Journal Watch May 17, 2018 Clopidogrel plus Aspirin Has Benefits for TIA or Minor Stroke]</ref><ref>Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA [https://www.nejm.org/doi/full/10.1056/NEJMoa1800410 N Engl J Med 2018; 379:215-225]</ref>
	*[[Anticoagulation]] not recommended for acute stroke (even for A-fib)		*[[Anticoagulation]] not recommended for acute stroke (even for A-fib)

Hoxbox: /* Non-tPA Candidate */

2019-10-23T10:52:29Z

Non-tPA Candidate

← Older revision		Revision as of 10:52, 23 October 2019
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	**Goal MAP for non-thrombolyzed, MAP < 150, per AHA guidelines<ref>Anton Helman. Emergency Medicine Cases. Episode 17 Part 1: Emergency Stroke Controversies. September 2011. https://emergencymedicinecases.com/episode-17-part-1-emergency-stroke-controversies/</ref>		**Goal MAP for non-thrombolyzed, MAP < 150, per AHA guidelines<ref>Anton Helman. Emergency Medicine Cases. Episode 17 Part 1: Emergency Stroke Controversies. September 2011. https://emergencymedicinecases.com/episode-17-part-1-emergency-stroke-controversies/</ref>
	*[[Aspirin]] 325mg (within 24-48hr)		*[[Aspirin]] 325mg (within 24-48hr)
			**add [[clopidogrel]] (600 mg loading followed by 75 mg daily for 30-90 days) prevents 15 strokes out of 1000 patients at a cost of 5 additional major noncerebral hemorrhages. <ref>[https://www.jwatch.org/na46776/2018/05/17/clopidogrel-plus-aspirin-has-benefits-tia-or-minor-stroke Journal Watch May 17, 2018 Clopidogrel plus Aspirin Has Benefits for TIA or Minor Stroke]</ref><ref>Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA [https://www.nejm.org/doi/full/10.1056/NEJMoa1800410 N Engl J Med 2018; 379:215-225]</ref>
	*[[Anticoagulation]] not recommended for acute stroke (even for A-fib)		*[[Anticoagulation]] not recommended for acute stroke (even for A-fib)

ClaireLewis at 01:13, 2 October 2019

2019-10-02T01:13:26Z

← Older revision		Revision as of 01:13, 2 October 2019
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	==Management==		==Management==
	To differentiate between tPA and non-tPA candidates see [[Thrombolysis in Acute Ischemic Stroke (tPA)]]		To differentiate between [[tPA]] and non-tPA candidates see [[Thrombolysis in Acute Ischemic Stroke (tPA)]]
	===Both tPA AND non-tPA candidates===		===Both tPA AND non-tPA candidates===
	*Prevent dehydration		*Prevent dehydration
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	*tPA		*tPA
	**See [[Thrombolysis in Acute Ischemic Stroke (tPA)]]		**See [[Thrombolysis in Acute Ischemic Stroke (tPA)]]
	*Hypertension		*[[Hypertension]]
	**Lower SBP to < 185, DBP to < 110		**Lower SBP to < 185, DBP to < 110
	**Goal MAP < 130		**Goal MAP < 130
	**Options:		**Options:
	***Labetalol 10–20 mg IV over 1–2 min; may repeat x1 '''OR'''		***[[Labetalol]] 10–20 mg IV over 1–2 min; may repeat x1 '''OR'''
	***Nitroglycerin paste, 1–2 in. to skin '''OR'''		***[[Nitroglycerin]] paste, 1–2 in. to skin '''OR'''
	***Nicardipine 5 mg/hr, titrate up by 2.5 mg/hr at 5-15 min intervals; max dose 15 mg/hr		***[[Nicardipine]] 5 mg/hr, titrate up by 2.5 mg/hr at 5-15 min intervals; max dose 15 mg/hr
	****When desired blood pressure attained reduce to 3 mg/hr		****When desired blood pressure attained reduce to 3 mg/hr

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	*Hypertension		*Hypertension
	**Allow permissive hypertension		**Allow permissive hypertension
	**If SBP > 220 or DBP > 120, lower by 25% over 24 hrs (drug of choice is ~~Nicardipine~~)<ref>Zha AM, et al. Recommendations for management of large hemispheric infarction. Curr Opin Crit Care. 2015; 21(2):91-8.</ref>		**If SBP > 220 or DBP > 120, lower by 25% over 24 hrs (drug of choice is [[nicardipine]])<ref>Zha AM, et al. Recommendations for management of large hemispheric infarction. Curr Opin Crit Care. 2015; 21(2):91-8.</ref>
	**Goal MAP for non-thrombolyzed, MAP < 150, per AHA guidelines<ref>Anton Helman. Emergency Medicine Cases. Episode 17 Part 1: Emergency Stroke Controversies. September 2011. https://emergencymedicinecases.com/episode-17-part-1-emergency-stroke-controversies/</ref>		**Goal MAP for non-thrombolyzed, MAP < 150, per AHA guidelines<ref>Anton Helman. Emergency Medicine Cases. Episode 17 Part 1: Emergency Stroke Controversies. September 2011. https://emergencymedicinecases.com/episode-17-part-1-emergency-stroke-controversies/</ref>
	*Aspirin 325mg (within 24-48hr)		*[[Aspirin]] 325mg (within 24-48hr)
	*Anticoagulation not recommended for acute stroke (even for A-fib)		*[[Anticoagulation]] not recommended for acute stroke (even for A-fib)

	===Endovascular Therapy===		===Endovascular Therapy===
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	**Functional independence of 32.6% with endovascular treatment and 19.1% with typical therapy		**Functional independence of 32.6% with endovascular treatment and 19.1% with typical therapy
	*Institutional dependent time window for intervention		*Institutional dependent time window for intervention
	*May require careful patient selection based on last known normal, ICA/prox MCA occlusion, and additional diagnostic studies such as CT perfusion study, Rapid MRI, etc<ref>Thrombectomy For Stroke At 6 To 16 Hours With Selection By Perfusion Imaging Albers, G.W., et al, N Engl J Med 378(8):708, February 22, 2018</ref>		*May require careful patient selection based on last known normal, ICA/prox MCA occlusion, and additional diagnostic studies such as CT perfusion study, Rapid [[brain MRI\|MRI]], etc<ref>Thrombectomy For Stroke At 6 To 16 Hours With Selection By Perfusion Imaging Albers, G.W., et al, N Engl J Med 378(8):708, February 22, 2018</ref>
	*Goal SBP <160 after endovascular therapy <ref>Smith M, Reddy U, Robba C, et al. Acute ischaemic stroke: challenges for the intensivist. Intensive Care Med. 2019</ref>		*Goal SBP <160 after endovascular therapy <ref>Smith M, Reddy U, Robba C, et al. Acute ischaemic stroke: challenges for the intensivist. Intensive Care Med. 2019</ref>

	===Cerebellar===		===Cerebellar===
	*Early neurosurgical consultation is needed (herniation may lead to rapid deterioration)		*Early neurosurgical consultation is needed ([[herniation Syndromes\|herniation]] may lead to rapid deterioration)
	*See [[Cerebellar Stroke]]		*See [[Cerebellar Stroke]]

	===Corticosteroids===		===[[Corticosteroids]]===
	*Cochrane review showed no benefit in mortality or functional outcomes<ref>Sandercock PA and Soane T. Corticosteroids for acute ischaemic stroke. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD000064.</ref>		*Cochrane review showed no benefit in mortality or functional outcomes<ref>Sandercock PA and Soane T. Corticosteroids for acute ischaemic stroke. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD000064.</ref>

Rossdonaldson1: /* Background */

2019-09-06T00:57:35Z

Background

← Older revision		Revision as of 00:57, 6 September 2019
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	==Background==		==Background==
			[[File:23-Sensory-Homonculus.png\|thumb\|Sensory Homonculus - courtesy AnatomyZone.com]]
	{{Ischemic Stroke Cause}}		{{Ischemic Stroke Cause}}