IV Thrombolytic Window
IV Alteplase / Tenecteplase within 4.5 hours of last known normal
Thrombectomy Window
Mechanical endovascular thrombectomy up to 24 hours for large vessel occlusions
BP Target for tPA
Blood pressure must be < 185/110 mmHg prior to thrombolytic infusion
Subarachnoid Hallmark
'Worst headache of life' (thunderclap); Xanthochromia on LP if CT negative
Cerebrovascular Territories & Stroke Syndromes
Anatomical localization based on neurologic exam deficits:
| Vessel Occluded | Motor / Sensory Deficits | Cortical Signs | High-Yield Board Clues |
|---|---|---|---|
| Middle Cerebral Artery (MCA) | Contralateral face and arm > leg motor and sensory loss | Dominant (left): Aphasia (Broca/Wernicke); Non-dominant (right): Hemineglect | Gaze deviation toward the side of the lesion; homonymous hemianopsia |
| Anterior Cerebral Artery (ACA) | Contralateral leg > face and arm motor and sensory deficit | Abulia, apathy, lack of spontaneous speech | Urinary incontinence; primitive reflexes (grasp reflex) |
| Posterior Cerebral Artery (PCA) | Contralateral sensory loss / thalamic pain | Homonymous hemianopsia with macular sparing | Visual hallucinations, prosopagnosia (inability to recognize faces) |
| Basilar Artery | Quadriparesis, cranial nerve palsies | 'Locked-In' syndrome (fully conscious, vertical eye movements intact) | Coma, pinpoint reactive pupils, decerebrate posturing |
Emergency Management of Acute Ischemic Stroke
Time is brain: follow the door-to-treatment milestones:
Immediate Neuroimaging
Non-contrast Head CT is first-line to rule out hemorrhage. (Early ischemic changes may be subtle or absent in the first 6 hours).
Thrombolytic Eligibility (Alteplase / Tenecteplase)
Within 3 hours (extended to 4.5 hours in select patients). Key contraindications: Hemorrhage on CT, prior intracranial hemorrhage, head trauma or stroke in past 3 months, active internal bleeding, platelet count < 100,000, INR > 1.7, or BP > 185/110 mmHg.
Endovascular Thrombectomy (EVT)
Indicated for large vessel occlusion (LVO) of the internal carotid or proximal MCA (M1) up to 24 hours from last known normal.
COMLEX / OMM Integration
NBOME High-Yield Correlate
Cranial Contraindications & Suboccipital Drainage
- Absolute Contraindication: Cranial osteopathy (OCF) is STRICTLY CONTRAINDICATED in acute hemorrhagic stroke or acute traumatic brain injury due to fluctuating intracranial pressures.
- Post-Acute Rehab: In stable post-stroke patients, gentle suboccipital release and thoracic inlet decompression support cerebral venous return and reduce post-stroke hypertonicity.
- Post-Acute Rehab: In stable post-stroke patients, gentle suboccipital release and thoracic inlet decompression support cerebral venous return and reduce post-stroke hypertonicity.
Board Traps & Common Distractors
- Trap: Aggressively lowering blood pressure in acute ischemic stroke without thrombolytic intent. Permissive hypertension (up to 220/120 mmHg) is maintained to preserve perfusion through collateral vessels in the ischemic penumbra.
- Trap: Missing a Subarachnoid Hemorrhage on early CT. A non-contrast head CT within 6 hours has 99% sensitivity for SAH. If CT is completely normal but suspicion remains high for a thunderclap headache, you MUST perform a lumbar puncture to evaluate for xanthochromia.