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  • Determine the time of onset (time the patient was last seen normal). This is extremely important, as thrombolysis is possible only within 3–4.5 hours of the onset
  • Was there any repetitive movement to suggest a seizure, as it is a contraindication to thrombolysis?

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  • Check vitals; BP must be <185/105 for treatment with intravenous tPA (Alteplase)
  • Check FAST
    • F – face (droop?)
    • A – arm (drift or paresis?)
    • S – speech (aphasic or dysarthric?)
    • T – time last seen normal
  • Assess for dysphagia – if present, insert nasogastric tube
  • Calculate NIH Stroke Scale

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Table Graphic Jump Location
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NIH Stroke Scale (0–30)
1a Level of consciousness
  • 0
  • 1
  • 2
  • 3
  • Alert
  • Drowsy
  • Stupor
  • Coma
  • 1b What month is it?
  • How old are you?
  • 0
  • 1
  • 2
  • Both correct
  • One correct
  • Both incorrect
  • 1c Make a fist
  • Close your eyes
  • 0
  • 1
  • 2
  • Both correct
  • One correct
  • Both incorrect
2 Best gaze
  • 0
  • 1
  • 2
  • Normal
  • Partial gaze palsy
  • Forced deviation
3 Visual fields
  • 0
  • 1
  • 2
  • 3
  • No visual loss
  • Partial hemianopia
  • Complete hemianopia
  • Bilateral hemianopia
4 Facial paresis
  • 0
  • 1
  • 2
  • 3
  • Normal
  • Minor paresis
  • Partial paresis
  • Complete palsy
5, 6, 7, 8 Motor (each arm and each leg)
  • 0
  • 1
  • 2
  • 3
  • 4
  • Normal
  • Drift
  • Some effort against gravity
  • No effort against gravity
  • No movement
9 Ataxia
  • 0
  • 1
  • 2
  • Absent
  • Present in one limb
  • Present in 2 or more limbs
10 Sensory
  • 0
  • 1
  • 2
  • Normal
  • Partial loss
  • Dense loss
11 Best language
  • 0
  • 1
  • 2
  • 3
  • No aphasia
  • Mild-moderate aphasia
  • Severe aphasia
  • Mute
12 Dysarthria
  • 0
  • 1
  • 2
  • Normal
  • Mild-moderate dysarthria
  • Unintelligible
13 Neglect
  • 0
  • 1
  • 2
  • No neglect
  • Partial neglect
  • Complete neglect

NIHSS < 3 is a relative contraindication to thrombolysis, unless deficit highly disabling (e.g., an isolated severe aphasia).

NIHSS > 24 has a high risk of hemorrhage; consider endovascular options.

NIHSS also has a prognostic value: a score ≥ 16 forecasts a high probability of death or severe disability, whereas a score of ≤ 6 forecasts a good recovery.

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Call

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  • Emergent vascular neurology consult
  • CT scanner – STAT non-contrast Head CT to rule out intracranial hemorrhage

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Labs: CBC, electrolytes, liver function, glucose, PT/INR, PTT, urine toxicology, ABG

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Table Graphic Jump Location
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Management: Revascularization
ModalityTime windowDoseProsCons
Intravenous-tPA (Alteplase)0–4.5 h0.1 mg/kg bolus, then 0.8 mg/kg drip over 1 h; maximum = 90 mg
  • Availability
  • No specialty staff needed
Contraindications (see below)
Intraarterial-tPA (Alteplase)0–6 h2–20 mg intra-arterially
  • Longer window
  • Lower dose
Highly trained team needed
Thrombectomy via MERCI, PENUMBRA, SOLITAIRE FR0–8 h
  • Up to INR of 3.0
  • Longest time window
  • Highly trained team needed
  • Highest procedural risk
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  • Time of onset >4.5 hours
  • Time of onset shortened to >3 hours when any of the following occur
    • Age > 80
    • History of both diabetes and stroke
    • Head CT with stroke > 1/3 of vessel territory
    • Current anticoagulant use regardless of INR/PTT
  • Serious head trauma, MI or stroke ...

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