Acute Ischemic & Hemorrhagic Stroke

Resuscitation Quick Ribbon (First 2 Minutes)

Tenecteplase (TNK):0.25 mg/kg IV bolus over 5 seconds (max 25 mg); preferred thrombolytic

Alteplase (tPA):0.9 mg/kg IV (max 90 mg); 10% bolus over 1 min, remaining 90% over 60 min

BP Target (Pre-Thrombolysis):Must be < 185/110 mmHg prior to TNK/tPA; use Nicardipine or Labetalol

BP Target (ICH / Hemorrhage):Target SBP 130–140 mmHg rapidly; avoid drops < 130 mmHg

Warfarin Reversal:4-Factor Prothrombin Complex Concentrate (4F-PCC) 25–50 U/kg + Vitamin K 10 mg IV

Bottom-Line Clinical Pearl

In acute ischemic stroke, establish exact time last known normal (LKN). Non-contrast CT rules out hemorrhage; CTA identifies Large Vessel Occlusion (LVO: ICA, MCA-M1/M2). IV thrombolysis window is < 4.5 hours (Tenecteplase 0.25 mg/kg IV single bolus preferred over Alteplase). Endovascular thrombectomy (EVT) window extends up to 24 hours for anterior circulation LVO based on DAWN/DEFUSE-3 imaging criteria. In hemorrhagic stroke, target SBP 130–140 mmHg within 1 hour using nicardipine and immediately reverse anticoagulation.

1. The Hyperacute Stroke Protocol (< 60 Minutes)

Time Goal	Step	Action Item	Clinical Threshold
0 min	Arrival & Triage	Activate Code Stroke, check fingerstick glucose	Glucose must be > 60 mg/dL (hypoglycemia mimics stroke)
< 10 min	Clinical Exam	Calculate NIHSS, establish Last Known Normal (LKN)	NIHSS >= 6 or disabling deficit indicates potential LVO
< 20 min	Imaging	Non-contrast CT head + CTA head/neck (arch to vertex)	NCCT rules out hemorrhage; CTA identifies LVO (ICA, M1, M2, basilar)
< 45 min	Decision & Thrombolytic	Tenecteplase (TNK) 0.25 mg/kg IV if < 4.5h from LKN	BP must be < 185/110 mmHg before pushing TNK
< 60 min	Endovascular Puncture	Transfer to angio suite if CTA demonstrates LVO	EVT indicated up to 24 hours with favorable perfusion profile