Get your attending!

Step 1: Obtain Last Known Well

  • Stroke treatments including tPA and thrombectomy both require last known well
    • <3-4.5 hours for tPA
    • <24 hours mechanical thrombectomy

Step 2: Finger Stick Blood Glucose

  • Hypoglycemia is classic mimic of CVA
  • Results can be obtained immediately

Step 3: STAT Head CT Without Contrast

  • Poor sensitivity for ischemic stroke
    • Primary use is identification of hemorrhagic stroke
    • Required prior to administration of tPA!

Step 4: Perform NIHSS

Step 5: Give tPA (If No Contraindications)

  • Follow department protocol and contraindications
    • Frequently being updated

Additional Reading


  1. Remy

    Great job Zack! I was wondering if you could do a section on the new guidelines for anterior circulation occlusion. what are your institutional guidelines for mechanical retrieval? would you send them off to tertiary care if in community ? or IR?
    Also, hypertension management in ischemic stroke prior to tpa? whats the anti hypertensive agent of choice?It seems like every attending has a different approach and of course it differs institution to institution !

    Stroke is a multidimensional diagnosis and patients usually present with multiple comorbidities…from cardioembolic sources to metabolic causes , do you have a specific way of creating a mental algorithm to be able to differentiate between them ?

    Thanks again and keep up the good work.


    • Zack

      Awesome questions Remy!

      I’ll start with the easier question- antihypertensive of choice. According to tintinallis you can use either nicardipine or labetelol to decrease bp to <185/110 in tPA candidates. Personal experience at my institution is that we tend to use nicardipine, but I've seen attendings use both.

      Regarding how we differentiate between etiologies, I haven't created an algorithm. But typically these patients will have basic labs drawn looking for metabolic causes (glucose is most important!) and then further workup continues after admission. Typically, between the lab work, MRI, echocardiogram, and vascular dopplers, the etiology will be found, but most of that is done inpatient.

      Your best question is regarding anterior circulation occlusion and mechanical retrieval! I'm not an expert on this by any means. I'm training at a community hospital, so in the past, all of these potential cases were being transfered to tertiary care for retrieval pending approval by neurology. Interestingly, we just hired a new neuro-IR guy and credentialed him for mechanical retrieval, but since I've been on off service haven't had a chance to work with him yet. I'll show him your question when I meet him and get his input!

      Does that answer your questions? What is your experience with this at your institution?

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