Clinical Tools.

The NIH Stroke Scale is a 15-item bedside neurological exam scored 0–42. Higher scores mean larger strokes; serial NIHSS is the quickest way to detect early extension or recovery.

• 1a, 1b, 1c — Level of consciousness, orientation, command following
• 2 — Best gaze
• 3 — Visual fields
• 4 — Facial palsy
• 5a / 5b — Motor arm (left, right)
• 6a / 6b — Motor leg (left, right)
• 7 — Limb ataxia
• 8 — Sensory
• 9 — Best language (aphasia)
• 10 — Dysarthria
• 11 — Extinction and inattention

Read the full NIHSS guide →

The functional outcome scale used in essentially every major stroke trial. Anchor it at baseline (admission) and at 90 days — everything else flows from there.

• 0 — No symptoms at all
• 1 — No significant disability; able to carry out all usual duties despite some symptoms
• 2 — Slight disability; unable to carry out previous activities, but independent
• 3 — Moderate disability; requires some help but walks unassisted
• 4 — Moderately severe disability; cannot walk unassisted, cannot attend to own bodily needs
• 5 — Severe disability; bedridden, requires constant care
• 6 — Dead

The Alberta Stroke Program Early CT Score grades MCA-territory early ischemic changes on non-contrast CT. Start at 10 and subtract one point for each region with hypoattenuation. Two axial slices, ten regions:

Historical thrombectomy threshold: ASPECTS ≥6.

Expanding threshold (large-core trials): SELECT2, ANGEL-ASPECT, RESCUE-Japan LIMIT, and TENSION have moved the eligible range down to ASPECTS 3–5 in selected patients.

Window: ischemic stroke within 4.5 hours of last known well (LKW). Extend to 9 hours in selected wake-up / unknown-onset cases with favorable perfusion imaging (WAKE-UP, EXTEND).

Tenecteplase (TNK): 0.25 mg/kg IV bolus, max 25 mg. Increasingly the agent of choice (AcT, TASTE).

Alteplase (tPA): 0.9 mg/kg IV, max 90 mg — 10% as bolus over 1 minute, 90% as infusion over 60 minutes.

Absolute exclusions to remember:

• Intracerebral hemorrhage on imaging (any volume)
• BP that cannot be lowered to <185/110 before treatment
• Active internal bleeding
• Recent intracranial surgery, head trauma, or prior ICH (within 3 months in most centers)
• INR >1.7, therapeutic LMWH within 24 hours, or DOAC within 48 hours (without reversal)

Compressing door-to-needle below 30 minutes requires parallel processing, not heroic individual effort. The high-yield interventions:

• EMS pre-notification with structured pre-arrival data (LKW, LVO screen, BP, glucose)
• Single-call activation of the entire stroke team direct to the CT suite
• Direct-to-CT from the EMS stretcher, bypassing the ED bay
• Parallel processing of imaging, point-of-care labs, NIHSS, history, and pharmacy preparation
• Tenecteplase at bedside, drawn in a syringe and ready to administer — removes pharmacy reconstitution from the critical path
• Automated imaging post-processing (ASPECTS, LVO detection, perfusion)
• Drip-and-ship for thrombectomy candidates, with image transfer in parallel with patient movement

Early window (0–6 h from LKW) — the classic 2015 cohort (MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, EXTEND-IA / HERMES):

• NIHSS ≥6
• ASPECTS ≥6
• Anterior-circulation LVO (ICA terminus, M1, proximal M2)
• Pre-stroke mRS ≤1
• Age ≥18

Late window (6–24 h) — DAWN, DEFUSE-3:

• Clinical/imaging mismatch on CTP or MRI
• Small ischemic core, large penumbra

Large-core (recent expansion): SELECT2, RESCUE-Japan LIMIT, ANGEL-ASPECT, and TENSION have demonstrated benefit even with ASPECTS 3–5 in selected patients. Basilar occlusion is supported by BAOCHE and ATTENTION.

The numbers most stroke teams work with:

• Pre-thrombolysis: <185/110 before any tPA / TNK
• Post-thrombolysis (first 24 h): <180/105
• Post-thrombectomy, successful (TICI 2b–3): <140/90 to <160/90 depending on institution (BP-TARGET, ENCHANTED-2/MT)
• Ischemic stroke not eligible for reperfusion: permissive hypertension; treat only if >220/120 or end-organ involvement
• Acute ICH: SBP <140 (INTERACT-2, ATACH-2) within the first few hours
• Aneurysmal SAH: SBP <160 until the aneurysm is secured

Every ischemic stroke:

• Vessel imaging head + neck (CTA or MRA)
• Brain MRI with DWI (confirms infarct, defines pattern)
• Echocardiogram (TTE; add bubble study for shunt evaluation)
• Cardiac monitoring for ≥24–72 hours inpatient telemetry
• Labs: CBC, BMP, A1c, lipid panel, troponin, PT/INR, PTT

Add for cryptogenic stroke (after standard workup is unrevealing):

• Prolonged outpatient monitoring (ZIO patch 14–30 days, or implantable loop recorder)
• Bubble study for PFO (with consideration of closure if young, large shunt, and no other source — CLOSE, REDUCE)
• Hypercoagulable workup in younger patients

Add for young stroke (<55):

• Thrombophilia panel (anticardiolipin, anti-β2-glycoprotein, lupus anticoagulant, factor V Leiden, prothrombin gene mutation, protein C/S, antithrombin)
• Vasculitis labs (ANA, ANCA, ESR, CRP)
• Dissection imaging (vessel wall MRI if clinically suggestive)
• Drug screen including cocaine and methamphetamine
• Pregnancy / postpartum considerations

Mechanistic classification of ischemic stroke. Drives secondary prevention.

• Large-artery atherosclerosis (LAA) — significant stenosis (≥50%) or occlusion in a clinically relevant artery
• Cardioembolic (CE) — high-risk source (AFib, mechanical valve, LV thrombus, recent MI with anterior wall hypokinesis, endocarditis)
• Small-vessel occlusion (SVO / lacunar) — <1.5 cm subcortical or brainstem lesion in a clinically appropriate location
• Other determined etiology — dissection, vasculitis, hypercoagulable, drug-induced, etc.
• Undetermined — cryptogenic, multiple competing mechanisms, or incomplete workup

Before the patient walks out:

• Antithrombotic: ASA, DAPT (for 21 days in qualifying minor strokes), or anticoagulation — plan and duration documented
• BP plan: target <130/80, regimen at discharge, adherence plan
• Statin: high-intensity (atorvastatin 80 mg or rosuvastatin 20–40 mg) unless contraindicated
• Glycemic control: A1c target <7% for most patients
• AFib decision: anticoagulation choice and timing (ELAN / OPTIMAS) if relevant
• Rehab disposition: home with OP therapy, acute inpatient rehab, SNF, or LTACH
• Follow-up: stroke clinic at 4–6 weeks; PCP within 2 weeks; PT/OT/SLP referrals
• Patient teaching: BE-FAST warning signs, medication adherence, secondary risk-factor goals

• Non-cardioembolic ischemic stroke: aspirin 81 mg daily (or clopidogrel 75 mg daily as alternative)
• Minor non-cardioembolic stroke (NIHSS ≤3) or high-risk TIA (ABCD² ≥4): dual antiplatelet therapy (ASA + clopidogrel) for 21 days, then ASA alone (CHANCE, POINT)
• Symptomatic intracranial atherosclerotic stenosis: DAPT for 90 days (SAMMPRIS), with aggressive risk-factor control
• Atrial fibrillation: DOAC preferred (apixaban, rivaroxaban, dabigatran, edoxaban) over warfarin in most patients
• Mechanical valve: warfarin (DOACs not adequate)
• LV thrombus, antiphospholipid syndrome: warfarin (DOACs not adequately studied)

After ischemic stroke in AFib (DOAC initiation):

• TIA / very small infarct: within 1–2 days
• Mild infarct: day 3–4
• Moderate infarct: day 6–7 (ELAN trial: early initiation non-inferior to delayed)
• Large infarct: day 12–14, with repeat imaging to exclude hemorrhagic transformation

ELAN (NEJM 2023) and OPTIMAS support earlier-than-historical initiation in most patients with imaging review.

After intracerebral hemorrhage (resuming AC):

• Lobar ICH: often deferred indefinitely if cerebral amyloid angiopathy is suspected; case-by-case
• Deep ICH from hypertensive vasculopathy: typically considered at 4–8 weeks once BP is well controlled