Last known nomral <3 hr

Sudden onset

Verifiable Neuro deficit of

  • Speech problem
  • visual field loss
  • unilateral weakness
  • ataxia

NIHSS: normal=0

  • LOC: 0-3
  • Speech
    • 2 questions: 0-2
    • 2 commands: 0-2
    • Dysarthria: 0-2
    • Aphasia: 0-3
  • Gaze: 0-2
  • Motor each limb: 0-4
  • Ataxia: 0-2
  • Sensory: 0-2
  • Extinction/Neglect: 0-2

Exclusion criteria

  • Significant head trauma or prior stroke in past 3 months
  • Symptoms suggest subarachnoid bleed
  • Arterial puncture at non-compressible site in past 7 days
  • History of intracranial hemorrhage
  • Intracranial neoplasm, AVM or aneurysm
  • Recent intracranial or intraspinal surgery
  • Elevated BP > 185/110 mm Hg)
  • Active internal bleeding

Exclusion criteria (Cont)

  • Acute bleeding diathesis, such as Platelet <100k/mm≥
  • Heparin received within 48 hours, with aPTT > upper limit
  • Current use of anticoagulant with INR >1.7 or PT >15 seconds
  • Current use of NOAC
  • Blood glucose >50 mg/dL
  • CT shows multilobar infarct (hypodensity >1/3 cerebral hemisphere)

Final check

  • Last known normal < 3 hr
  • Reviewed Exclusion criteria
  • Blood glucose >50
  • BP < 185/110, if high start nicardipine
  • CT head no bleed

tPA dose

  • 0.9 mg/kg, up to 90 mg
  • 10 percent bolus, rest over 1 hr

Last known normal

4 to 4.5 hours

No tpa

If any of the following

  • over 80 years old
  • taking oral anticoagulant
  • NIHSS > 25
  • History of Stroke and Diabetes

Post TPA

first 24 hours

  • No antiplatelet, anticoagulant for 24 hours
  • Bed rest
  • Keep BP <180/105
  • Avoid arterial puncture, Foley, NG
  • VTE prophylaxis with SCD
  • CT or MRI at 24 hour post tpa, check for bleed

TPA not given

  • Docuement reason
  • Give Aspirin 325 mg po or 300 mg per rectal
  • Permissive Hypertension systolic up to 210
  • Bed rest
  • If creatinine ok, get CTA head and neck
  • VTE prophylaxis
  • Lipid in am, high intensity statin if needed
  • If atrial fibrillation, consider anticoagulation
  • ST, OT, PT
  • Rehab