Definition & Core Concept

Acute Ischemic Stroke (AIS) is a catastrophic, time-sensitive neurological emergency defined by the sudden cessation of cerebral blood flow, typically secondary to a thrombotic or embolic arterial occlusion. Stroke remains a leading cause of long-term global disability; in the United States alone, over 800,000 individuals experience an incident or recurrent stroke annually, and the prevalence is projected to increase sharply with an aging population.

The pathophysiological principle driving AIS management is time-dependent neuronal salvage, encapsulated by the axiom ‘time is brain.’ Following occlusion, the central infarct core is rapidly subjected to irreversible necrosis, while the surrounding hypoperfused tissue—the ischemic penumbra—remains viable but electrically silent. If rapid reperfusion is achieved, the penumbra can be fully salvaged.

Executive Triage Summary

Priority Assessment:

• ABCs: Airway, Breathing, Circulation
• Time of symptom onset: Critical for thrombolysis eligibility
• NIHSS: Quantifies severity; score ≥10 suggests large vessel occlusion
• Imaging: STAT non-contrast CT head to exclude hemorrhage
• Eligibility: Assess for IV thrombolysis (4.5-hour window, extended to 9 hours with penumbral imaging)
• Large vessel occlusion: Evaluate for endovascular thrombectomy (up to 24 hours)

Institutional Metrics (AHA/ASA Targets):

• Door-to-physician evaluation: ≤10 minutes
• Door-to-neuroimaging: ≤20 minutes
• Door-to-needle (thrombolytic): ≤60 minutes

Primary Survey (ABCDEs)

A – Airway:

• Protect airway if GCS <8 or unable to protect
• Assess for aspiration risk

B – Breathing:

• Maintain SpO2 ≥94%
• Supplemental oxygen if needed (hypoxia worsens ischemic injury)

C – Circulation:

• Assess blood pressure (SBP 140-180 mmHg in non-thrombolyzed patients; <185/110 for thrombolysis candidates)
• Rhythm strip for atrial fibrillation
• IV access ×2

D – Disability (Neurological):

• NIHSS: Standardized neurological assessment
• Assess for facial droop, arm/leg drift, aphasia, visual fields, ataxia
• Check glucose (hypoglycemia mimics stroke)

E – Exposure/Environment:

• Vital signs, temperature
• Full neurological exam
• Rapid glucose, ECG

STAT Diagnostics (POCUS/FAST)

STAT Imaging:

• Non-contrast CT head: Urgent (≤20 minutes) to rule out hemorrhage
• CT Angiography (CTA): Evaluate for large vessel occlusion
• CT Perfusion (CTP): Assess penumbra, guide extended window therapy
• MRI: Used in select scenarios, more sensitive for early ischemia

STAT Laboratory:

• Point-of-care glucose
• PT/INR
• Complete blood count (CBC)
• Comprehensive metabolic panel (CMP)
• Cardiac biomarkers (troponin)

Imaging Interpretation:

• ASPECTS: CT score for early ischemic changes
• Penumbral imaging: Core vs. mismatch (viable penumbra)
• Collateral assessment: Predicts EVT benefit

Secondary Survey

Diagnostic Evaluation:

• Echocardiogram: Transthoracic or transesophageal (cardioembolic source)
• Telemetry: Continuous cardiac monitoring for atrial fibrillation
• Carotid ultrasound: If carotid stenosis is suspected
• Hypercoagulability workup: In young patients or unexplained stroke

Stroke Subtype Classification (TOAST):

• Large artery atherosclerosis
• Cardioembolism (most common)
• Small vessel occlusion (lacunar)
• Stroke of other determined etiology
• Stroke of undetermined etiology

Secondary Prevention:

• Antiplatelet therapy (DAPT × 21 days then single agent)
• Anticoagulation for atrial fibrillation (NOAC preferred)
• Statin therapy (high-intensity)
• Blood pressure control (target <130/80)
• Lifestyle modifications

Disposition & Handoff

Admission Criteria:

• All acute stroke patients require admission
• Stroke unit: For patients receiving IVT or EVT
• Telemetry: For cardiac monitoring and rhythm detection
• ICU: For patients with large infarctions (malignant edema risk), significant NIHSS, or altered mental status

Handoff (SBAR):

• Situation: Acute ischemic stroke, onset at [time], NIHSS [score]
• Background: [Risk factors, medications, imaging findings]
• Assessment: [Received IVT/EVT, current NIHSS, complications]
• Recommendation: [Continue monitoring, blood pressure targets, swallow evaluation, DVT prophylaxis]

Discharge Planning:

• Swallow evaluation before oral intake
• Physical/occupational/speech therapy referral
• Secondary prevention medications
• Follow-up with stroke neurologist (within 7-14 days)

Discharge & Outpatient Follow-up

• Blood pressure: Target <130/80 mmHg
• Anticoagulation: If atrial fibrillation, start NOAC (apixaban, rivaroxaban, edoxaban) within 4-14 days post-stroke
• Antiplatelet: Continue DAPT × 21 days then aspirin or clopidogrel monotherapy
• Statin: High-intensity (atorvastatin 40-80 mg or rosuvastatin 20-40 mg)
• Glycemic control: A1C <7% if diabetic
• Smoking cessation: Strongly counsel
• Follow-up: Neurology in 7-14 days
• Rehabilitation: PT, OT, ST as indicated
• Carotid revascularization: If ≥70% stenosis and stroke in territory

Literature & Guidelines

Prabhakaran S, Gonzalez NR, Zachrison KS, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2026;57(3):e1-e120. doi:10.1161/STR.0000000000000513.

Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46-e110.

Menon BK, Buck BH, Singh N, et al. Tenecteplase versus alteplase for acute ischemic stroke: a systematic review and meta-analysis. Lancet Neurol. 2025;24(2):115-124.