Acute Ischemic Stroke: Diagnosis and Management
Written by Dr. Muhammad Salar Raza · Manually reviewed by Dr. Muhammad Salar Raza · Content updated
Clinical Pathway
Recognize stroke with sudden focal deficits: face droop, arm weakness, speech disturbance, and time of onset documented immediately. Obtain a non-contrast CT head without delay to exclude hemorrhage, and check glucose. Eligible patients presenting within 4.5 hours receive intravenous thrombolysis with alteplase after hemorrhage and contraindications are excluded. Large vessel occlusion within 24 hours may qualify for mechanical thrombectomy. Give aspirin once bleeding is excluded (or after 24 hours post-thrombolysis), manage blood pressure permissively unless thrombolysed, admit to a stroke unit, and start secondary prevention with antiplatelet or anticoagulation for AF, statin, and risk-factor control.
Clinical Reasoning
Time is brain: each minute of large vessel occlusion destroys roughly 1.9 million neurons, so the non-contrast CT is the single investigation that gates thrombolysis and must not be delayed by MRI. Glucose must be checked first because hypoglycemia perfectly mimics stroke. Before thrombolysis, blood pressure must be brought below 185/110 mmHg; without thrombolysis, hypertension is tolerated up to 220/120 mmHg because cerebral autoregulation is impaired. The classic distractor is giving aspirin before imaging; antiplatelets wait until hemorrhage is excluded. Vertigo, diplopia, and crossed signs point to posterior circulation strokes that CT can miss early.
Sample MCQ
A 68-year-old man presents 2 hours after sudden onset of right-sided weakness and aphasia. Glucose is normal and non-contrast CT head shows no hemorrhage. Blood pressure is 170/95 mmHg and he has no contraindications. What is the most appropriate next step?
- AIntravenous alteplase
- BImmediate aspirin 300 mg before any imaging findings develop
- CHeparin infusion
- DWait for MRI brain before any treatment
Correct Answer: Intravenous alteplase
He is within the 4.5-hour thrombolysis window, hemorrhage is excluded on CT, and his blood pressure is below the 185/110 mmHg threshold, so intravenous alteplase offers the best chance of functional recovery. Aspirin is given only after hemorrhage is excluded and, in thrombolysed patients, is delayed 24 hours; it is a secondary prevention measure, not acute reperfusion therapy. Heparin infusion is not recommended in acute ischemic stroke because bleeding risk outweighs benefit. MRI adds sensitivity but delays reperfusion; treatment must not wait for it when the CT is non-diagnostic of bleed and the window is open.
Guidelines and further reading
Related Clinical Topics
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