🧠 ACUTE STROKE – INDIA

COMPREHENSIVE DUAL-LEVEL CARE PROTOCOL

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🏥 LEVEL OF CARE OVERVIEW

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⏱️ CRITICAL TIME TARGETS

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🟢 PART 1 — PRIMARY CARE

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1️⃣ STROKE RECOGNITION

FAST Assessment

Letter	Assessment	Positive Finding
F	Face	Facial droop (ask to smile)
A	Arms	Arm drift (raise both arms)
S	Speech	Slurred or inappropriate speech
T	Time	Note exact symptom onset time

Symptom Onset Time – Critical Documentation

Scenario	Time to Record
Patient/witness knows exact time	Record that time
Found with symptoms	Last Known Well (LKW) time
Wake-up stroke	Time went to sleep = LKW
Unknown onset, no witness	Time last seen normal = LKW

⚠️ LKW time determines thrombolysis/thrombectomy eligibility – document precisely

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2️⃣ DIFFERENTIAL DIAGNOSIS (STROKE MIMICS)

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3️⃣ IMMEDIATE STABILISATION

Blood Glucose Management at Primary Care

RBS	Action
< 60 mg/dL	25 mL of 25% Dextrose IV → Recheck in 15 min
60-140 mg/dL	No intervention needed
140-180 mg/dL	Acceptable; no urgent treatment
> 180 mg/dL	Avoid dextrose-containing fluids; will need insulin at stroke centre

⚠️ Hypoglycaemia can mimic stroke – ALWAYS check RBS before labeling as stroke

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4️⃣ BLOOD PRESSURE MANAGEMENT AT PRIMARY CARE

General Principle

DO NOT aggressively lower BP in acute stroke unless extreme values

Lowering BP in ischemic stroke may worsen infarct. Only treat if dangerously high.

BP Thresholds for Treatment at Primary Level

Scenario	Treat if BP exceeds	Target
Presumed ischemic stroke (thrombolysis candidate)	SBP > 185 or DBP > 110	< 185/110 before transfer
Presumed ischemic stroke (NOT thrombolysis candidate)	SBP > 220 or DBP > 120	Reduce by 15% in 24h
Suspected hemorrhagic stroke	SBP > 180	SBP 140-160 (gentle)
Hypertensive emergency with end-organ damage	Any with end-organ signs	Reduce by 20-25%

Antihypertensive Options at Primary Care

Drug	Dose	Route	Notes
Labetalol	10-20 mg	IV over 2 min	Repeat q10-20 min; max 300 mg
Labetalol	100-200 mg	PO	If IV not available
Amlodipine	5 mg	PO	Slower onset
Nitroglycerin	5-10 mg	Transdermal patch	Avoid in suspected ICH

⛔ Avoid sublingual Nifedipine – unpredictable BP drop, risk of worsening stroke

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5️⃣ MEDICATIONS AT PRIMARY CARE

What TO Give

Drug	Indication	Dose
IV Normal Saline	Fluid maintenance	1-2 mL/kg/hr
Dextrose 25%	If RBS < 60	25-50 mL IV
Labetalol	If BP exceeds thresholds	See above
Antiemetic (Ondansetron)	If vomiting	4 mg IV
Paracetamol	If fever > 38°C	1 g IV/PO

What NOT to Give

⛔ Avoid	Reason
Aspirin/Antiplatelets	CT not done – may be hemorrhagic
Anticoagulants (Heparin, LMWH)	May be hemorrhagic
Mannitol	Reserve for definite ↑ICP at higher centre
Sublingual Nifedipine	Precipitous BP drop
Dextrose-containing fluids (if RBS normal)	Worsens ischemic injury
Sedatives	Mask neurological assessment

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6️⃣ TRANSFER PROTOCOL

Transfer Urgency

Patient Type	Urgency
Any suspected stroke < 24 hrs onset	IMMEDIATE
Suspected stroke with ↓consciousness	IMMEDIATE (Highest priority)
TIA (symptoms resolved)	URGENT (same day)

Pre-Transfer Checklist

Item	Details	☑️
Symptom onset / LKW time documented	CRITICAL for thrombolysis decision	☐
RBS checked and corrected	Exclude hypoglycemia	☐
BP recorded	Know baseline	☐
IV access secured	Functional line	☐
NPO status	Nothing by mouth	☐
Current medications documented	Especially anticoagulants	☐
Allergies documented	Drug allergies	☐
Pre-alert receiving stroke centre	Call ahead	☐

Critical Information for Receiving Centre

Information	Why Critical
Exact onset / LKW time	Thrombolysis eligibility
Current anticoagulant use	Thrombolysis contraindication; may need reversal
Recent surgery/bleeding	Thrombolysis contraindication
Current BP	Guide acute management
Blood glucose	Rule out mimic
Baseline function	mRS pre-stroke; guides treatment decisions

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🔵 PART 2 — STROKE CENTRE (Secondary/Tertiary Care)

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7️⃣ EMERGENCY DEPARTMENT PROTOCOL

Immediate Actions (Door to 10 min)

Action	Target Time
Physician assessment	≤ 10 min
Activate Stroke Team/Code Stroke	Immediate
Confirm onset / LKW time	Immediate
Rapid neurological exam (NIHSS)	≤ 15 min
IV access (if not present)	≤ 5 min
Blood samples drawn	≤ 10 min
ECG	≤ 15 min
Transport to CT	≤ 15 min

Blood Tests

Test	Purpose	Required Before tPA?
RBS (glucometer)	Exclude hypoglycemia	✅ YES
CBC	Baseline; plt for thrombectomy	Only platelet count
PT/INR	Anticoagulant use	Only if on warfarin
aPTT	Heparin use	Only if on heparin
Creatinine	CKD status	No (don't wait)
Troponin	Cardiac source	No (don't wait)

⚠️ Do NOT wait for blood results (except RBS and INR if on warfarin) to start thrombolysis

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8️⃣ NIHSS (National Institutes of Health Stroke Scale)

Complete NIHSS Scoring Table

Item	Assessment	Score
1a	Level of Consciousness	0-3
	Alert	0
	Drowsy (arousable with minor stimulation)	1
	Stuporous (requires repeated/strong stimulation)	2
	Unresponsive / Coma	3
1b	LOC Questions (month, age)	0-2
	Both correct	0
	One correct	1
	Neither correct	2
1c	LOC Commands (open/close eyes, grip/release)	0-2
	Obeys both correctly	0
	Obeys one correctly	1
	Neither	2
2	Best Gaze (horizontal eye movement)	0-2
	Normal	0
	Partial gaze palsy	1
	Forced deviation / Total gaze paresis	2
3	Visual Fields	0-3
	No visual loss	0
	Partial hemianopia	1
	Complete hemianopia	2
	Bilateral hemianopia / Blind	3
4	Facial Palsy	0-3
	Normal	0
	Minor (flattened nasolabial fold)	1
	Partial (lower face)	2
	Complete (upper and lower face)	3
5	Motor Arm (L and R separately; 5a=Left, 5b=Right)	0-4 each
	No drift (holds 90°/45° for 10 sec)	0
	Drift (drifts but doesn't hit bed)	1
	Some effort against gravity	2
	No effort against gravity	3
	No movement	4
6	Motor Leg (L and R separately; 6a=Left, 6b=Right)	0-4 each
	No drift (holds 30° for 5 sec)	0
	Drift	1
	Some effort against gravity	2
	No effort against gravity	3
	No movement	4
7	Limb Ataxia (finger-nose, heel-shin)	0-2
	Absent	0
	Present in one limb	1
	Present in two or more limbs	2
8	Sensory (pinprick)	0-2
	Normal	0
	Mild-moderate loss	1
	Severe/total loss	2
9	Best Language	0-3
	No aphasia	0
	Mild-moderate aphasia	1
	Severe aphasia	2
	Mute / Global aphasia	3
10	Dysarthria	0-2
	Normal	0
	Mild-moderate (can be understood)	1
	Severe / Unintelligible / Mute	2
11	Extinction/Inattention	0-2
	No abnormality	0
	One modality affected	1
	Profound (more than one modality)	2

Total NIHSS Score: 0-42

NIHSS Interpretation

Score	Severity	Clinical Implication
0	No stroke symptoms	Consider TIA or resolved stroke
1-4	Minor stroke	May not benefit from thrombectomy
5-15	Moderate stroke	Strong thrombolysis/thrombectomy candidate
16-20	Moderate-severe	Thrombectomy if LVO; higher risk
21-42	Severe stroke	Guarded prognosis; discuss with family

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9️⃣ NEUROIMAGING

CT Brain Interpretation

Finding	Interpretation	Action
Hyperdense artery sign	Clot in vessel (e.g., MCA)	Supports LVO; consider thrombectomy
Loss of grey-white differentiation	Early ischemic change	Note for ASPECTS
Sulcal effacement	Early edema	Note for ASPECTS
Hypodensity	Established infarct	If >1/3 MCA territory = relative CI for lysis
Hyperdensity (bright)	HEMORRHAGE	⛔ No thrombolysis
Normal CT	May still be acute ischemic stroke	Proceed with thrombolysis if eligible

ASPECTS Score (Alberta Stroke Program Early CT Score)

10 regions in MCA territory – subtract 1 point for each region with early ischemic changes

ASPECTS	Interpretation	Implication
10	Normal	Good candidate for reperfusion
7-9	Small early changes	Proceed with reperfusion
4-6	Moderate changes	Discuss risk/benefit for thrombectomy
0-3	Extensive changes	Poor prognosis; thrombectomy unlikely to help

CT Angiography (CTA)

Finding	Significance
ICA occlusion	LVO – thrombectomy candidate
M1 MCA occlusion	LVO – thrombectomy candidate
M2 MCA occlusion	Thrombectomy may be considered
Basilar artery occlusion	Thrombectomy up to 24 hrs in selected cases
No occlusion	Small vessel stroke; no thrombectomy indicated

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🔟 ISCHEMIC STROKE – ACUTE MANAGEMENT

Step-by-Step Decision Process

Step	Decision Point	Action
1	CT shows hemorrhage?	YES → Go to ICH protocol (Section 12)
2	Symptom onset ≤ 4.5 hours?	YES → Evaluate for IV thrombolysis
3	Thrombolysis contraindicated?	Check table below
4	BP ≤ 185/110?	If NO → Lower BP first
5	Start IV Alteplase/Tenecteplase	Door-to-needle ≤ 60 min
6	LVO on CTA?	YES → Evaluate for thrombectomy
7	Thrombectomy criteria met?	Transfer to comprehensive stroke centre

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IV THROMBOLYSIS PROTOCOL

Thrombolysis Eligibility

Criterion	Requirement
Diagnosis	Acute ischemic stroke causing measurable deficit
Age	≥ 18 years (relative CI if >80 yrs for 3-4.5 hr window)
Time window	≤ 4.5 hours from onset/LKW
CT Brain	No hemorrhage; no extensive established infarct
BP	≤ 185/110 mmHg before and during infusion

Absolute Contraindications

Contraindication
Intracranial hemorrhage on CT
Subarachnoid hemorrhage (suspected or confirmed)
Ischemic stroke or head trauma within 3 months
Intracranial/intraspinal surgery within 3 months
History of intracranial hemorrhage
GI or urinary bleeding within 21 days
Active internal bleeding
Arterial puncture at non-compressible site within 7 days
Known intracranial neoplasm, AVM, or aneurysm
Infective endocarditis
Aortic dissection (suspected)
INR > 1.7 or PT > 15 seconds
Platelet count < 100,000/mm³
Heparin within 48 hrs with elevated aPTT
DOAC within 48 hrs (or abnormal drug-specific assay)
Blood glucose < 50 mg/dL

Relative Contraindications (3-4.5 hour window)

Factor	Consideration
Age > 80 years	Higher bleeding risk; discuss with patient/family
NIHSS > 25	Severe stroke; higher bleed risk
Oral anticoagulant use (any)	Even if INR ≤ 1.7
History of DM + prior stroke	Higher hemorrhagic transformation risk

Thrombolytic Agents – Dosing

Agent	Dose	Administration
Alteplase (tPA)	0.9 mg/kg (max 90 mg)	10% as IV bolus over 1 min; remaining 90% as infusion over 60 min
Tenecteplase (TNK)	0.25 mg/kg (max 25 mg)	Single IV bolus over 5-10 seconds

📌 Tenecteplase is increasingly preferred: single bolus, non-inferior efficacy, possibly lower ICH risk

Tenecteplase Weight-Based Dosing (0.25 mg/kg)

Weight (kg)	Dose (mg)
50	12.5
60	15
70	17.5
80	20
90	22.5
≥100	25 (max)

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BP MANAGEMENT DURING/AFTER THROMBOLYSIS

Phase	Target
Before thrombolysis	Must be ≤ 185/110
During thrombolysis	Maintain ≤ 185/110
First 24 hours post-lysis	Maintain ≤ 180/105

IV Antihypertensives for Thrombolysis Candidates

Drug	Dosing	Notes
Labetalol	10-20 mg IV over 1-2 min; repeat q10-20 min (max 300 mg)	First-line
Labetalol infusion	2-8 mg/min	If boluses ineffective
Nicardipine	5 mg/hr IV; increase by 2.5 mg/hr q5-15 min (max 15 mg/hr)	Alternative
Clevidipine	1-2 mg/hr; titrate by doubling q90 sec (max 21 mg/hr)	If available

⚠️ If BP cannot be controlled to ≤ 185/110, DO NOT give thrombolysis

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POST-THROMBOLYSIS MONITORING

Parameter	Frequency
Neurological exam (NIHSS)	q15 min × 2 hrs → q30 min × 6 hrs → q1 hr × 16 hrs
BP	q15 min × 2 hrs → q30 min × 6 hrs → q1 hr × 16 hrs
Signs of bleeding	Continuous

Post-Thrombolysis Complications

Complication	Signs	Action
Symptomatic ICH	New headache, ↓GCS, new deficit, vomiting	STOP infusion; Stat CT; Cryoprecipitate/TXA
Angioedema	Tongue/lip swelling, stridor	Stop infusion; Adrenaline; Airway management
Systemic bleeding	Bleeding from puncture sites, GI, urinary	Stop infusion; Transfuse; TXA
Reperfusion injury	Worsening edema; hemorrhagic transformation	Supportive; manage ICP

Haemorrhagic Transformation Management

Action	Details
Stop Alteplase/TNK infusion	Immediately
Stat CT head	Confirm ICH
Cryoprecipitate	10 units IV
Tranexamic Acid (TXA)	1 g IV over 10 min
Platelet transfusion	If plt < 100,000
Reverse anticoagulation	As per pre-stroke medications
Neurosurgery consult	For large hematomas

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MECHANICAL THROMBECTOMY

Indications (Standard – Strong Evidence)

Criterion	Requirement
Diagnosis	Acute ischemic stroke with LVO
Occluded vessel	ICA or MCA (M1)
Age	≥ 18 years
NIHSS	≥ 6
ASPECTS	≥ 6
Pre-stroke mRS	0-1 (functionally independent)
Time window	≤ 6 hours from onset/LKW

Extended Window (6-24 hours) – DAWN/DEFUSE-3 Criteria

Criterion	DAWN	DEFUSE-3
Time	6-24 hours	6-16 hours
Imaging	CT/MR perfusion	CT/MR perfusion
Key concept	Clinical-core mismatch	Perfusion-core mismatch
Core infarct	Small core on DWI/CT	Ischemic core < 70 mL
Mismatch	NIHSS ≥ 10 with small core	Mismatch ratio ≥ 1.8

Vessels Eligible for Thrombectomy

Vessel	Evidence Level
ICA (intracranial)	Strong
MCA M1	Strong
MCA M2	Moderate (consider)
Basilar artery	Strong (up to 24 hrs in selected)
ACA	Limited evidence
PCA	Limited evidence

📌 If thrombectomy indicated but not available, transfer to Comprehensive Stroke Centre immediately (even if thrombolysis given)

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1️⃣1️⃣ NON-LVO ISCHEMIC STROKE / NOT REPERFUSION CANDIDATE

Management for Patients NOT Receiving Thrombolysis/Thrombectomy

Component	Details
Antiplatelet	Start within 24-48 hrs (immediately if no reperfusion therapy)
BP Management	Permissive hypertension (do not lower unless > 220/120)
Glucose	Target 140-180 mg/dL
Temperature	Treat fever > 38°C
DVT Prophylaxis	IPC immediately; LMWH after 24-48 hrs if immobile
Swallow screen	Before any oral intake
Statin	High-intensity statin (Atorvastatin 40-80 mg)

Antiplatelet Selection (Based on UK NICE/RCP & AHA/ASA Guidelines)

By Stroke Severity

Stroke Type	Day 1 (Loading)	Days 2-14	Days 15-21	Day 22 onwards
TIA	Aspirin 300 mg + Clopidogrel 300 mg	Aspirin 75 mg + Clopidogrel 75 mg (DAPT)	DAPT continued	Clopidogrel 75 mg monotherapy (lifelong)
Minor Stroke (NIHSS ≤ 3)	Aspirin 300 mg + Clopidogrel 300 mg	Aspirin 75 mg + Clopidogrel 75 mg (DAPT)	DAPT continued	Clopidogrel 75 mg monotherapy (lifelong)
Moderate-Severe Stroke (NIHSS > 3)	Aspirin 300 mg	Aspirin 300 mg daily	Aspirin 300 mg daily	Clopidogrel 75 mg monotherapy (lifelong)
Post-Thrombolysis (any severity)	⛔ NO antiplatelet	Start Aspirin 300 mg after 24 hrs (if CT confirms no ICH)	Continue Aspirin 300 mg	Clopidogrel 75 mg monotherapy (lifelong)

📌 Key Points:

• DAPT (Aspirin + Clopidogrel) is ONLY for TIA and Minor Stroke (NIHSS ≤ 3) – based on CHANCE and POINT trials
• Moderate-Severe Stroke (NIHSS > 3): Aspirin alone × 14 days, then switch to Clopidogrel
• Clopidogrel is preferred over Aspirin for long-term secondary prevention (CAPRIE trial)
• Post-thrombolysis: Wait 24 hours and confirm no hemorrhage on CT before starting antiplatelet

Evidence Base

Trial	Finding
CHANCE (2013)	DAPT × 21 days reduced recurrent stroke by 32% in TIA/minor stroke
POINT (2018)	DAPT benefit mainly in first 21 days; increased bleeding with longer duration
CAPRIE (1996)	Clopidogrel slightly superior to Aspirin for long-term secondary prevention
UK NICE (2023)	Recommends Clopidogrel as preferred long-term antiplatelet after stroke

Why NOT DAPT for Moderate-Severe Stroke?

Reason
CHANCE/POINT trials excluded patients with NIHSS > 3-5
Higher risk of hemorrhagic transformation in larger infarcts
Bleeding risk outweighs benefit
No proven efficacy of DAPT in larger strokes

When to Start Anticoagulation (Cardioembolic Stroke with AF)

📌 Repeat CT before starting anticoagulation in moderate-severe strokes

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1️⃣2️⃣ INTRACEREBRAL HEMORRHAGE (ICH)

ICH vs Ischemic Stroke – Key Differences

Feature	Ischemic Stroke	ICH
CT appearance	Hypodense (dark) or normal	Hyperdense (bright/white)
Thrombolysis	May be indicated	⛔ CONTRAINDICATED
Antiplatelets	Start within 24-48 hrs	Hold; restart cautiously
BP target	140-180 (post-lysis: <180)	< 140 mmHg (if presenting SBP 150-220)
Anticoagulant reversal	May need for thrombectomy	URGENT

ICH Score (Prognostic)

Component	Points
GCS
3-4	2
5-12	1
13-15	0
ICH Volume
≥ 30 mL	1
< 30 mL	0
IVH (Intraventricular extension)
Yes	1
No	0
Infratentorial origin
Yes	1
No	0
Age
≥ 80 years	1
< 80 years	0

ICH Score	30-Day Mortality
0	0%
1	13%
2	26%
3	72%
4	97%
5-6	~100%

ICH – Acute Management

Blood Pressure

Presenting SBP	Target	Agent
150-220 mmHg	< 140 mmHg within 1 hour	Nicardipine or Labetalol infusion
> 220 mmHg	Reduce by ~20% initially	Aggressive IV therapy

IV Antihypertensives for ICH

Drug	Dosing
Nicardipine	5 mg/hr; increase by 2.5 mg/hr q5-15 min (max 15 mg/hr)
Labetalol	10-20 mg IV bolus; then 2-8 mg/min infusion
Esmolol	250-500 μg/kg bolus → 50-200 μg/kg/min

Anticoagulant Reversal

Anticoagulant	Reversal Agent	Dose
Warfarin	Vitamin K	10 mg IV slow
	4-Factor PCC (preferred)	25-50 IU/kg
	FFP (if PCC unavailable)	15-20 mL/kg
Dabigatran	Idarucizumab	5 g IV
	If unavailable: PCC	50 IU/kg
Rivaroxaban / Apixaban / Edoxaban	Andexanet alfa (if available)	Per protocol
	4-Factor PCC	50 IU/kg
Heparin (UFH)	Protamine	1 mg per 100 U heparin (last 2-3 hrs)
Enoxaparin	Protamine	1 mg per 1 mg enoxaparin (given in last 8 hrs)

Additional ICH Management

Component	Action
Platelet transfusion	If on antiplatelets AND surgical candidate (routine transfusion not recommended)
Tranexamic Acid	1 g IV may be considered within 3 hrs (TICH-2: non-significant trend)
Glucose	Target 140-180 mg/dL
Temperature	Target normothermia; treat fever
ICP Management	If signs of herniation (see below)
Seizure prophylaxis	NOT routine; treat clinical seizures
DVT prophylaxis	IPC immediately; LMWH after 48-72 hrs if stable

Surgical Intervention in ICH

Indication	Consideration
Cerebellar hemorrhage > 3 cm	Strong indication – decompression life-saving
Cerebellar hemorrhage with hydrocephalus	EVD + consider evacuation
Lobar ICH > 30 mL, < 1 cm from surface	Consider surgical evacuation
IVH with hydrocephalus	EVD
Deep hemorrhage (basal ganglia, thalamus)	Surgery generally NOT beneficial

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1️⃣3️⃣ INCREASED INTRACRANIAL PRESSURE (ICP) MANAGEMENT

Signs of Raised ICP / Herniation

Sign	Description
Decreasing GCS	Progressive decline
Cushing's triad	Hypertension + Bradycardia + Irregular respiration
Pupillary changes	Unilateral or bilateral fixed dilated pupil
Posturing	Decorticate or decerebrate
New cranial nerve palsies	CN III, VI

ICP Management Ladder

Step	Intervention	Details
1	Head positioning	Elevate HOB 30°; keep head midline
2	Avoid hyperthermia	Target normothermia
3	Avoid hypoxia/hypercapnia	SpO₂ > 94%; avoid hyperventilation unless herniating
4	Sedation	If intubated (Propofol, Midazolam)
5	Osmotherapy	Mannitol OR Hypertonic saline
6	Brief hyperventilation	Target PaCO₂ 30-35 (only if acute herniation)
7	Neurosurgical intervention	Decompressive craniectomy or hematoma evacuation

Osmotherapy Dosing

Agent	Dose	Notes
Mannitol 20%	1-1.5 g/kg IV bolus	Over 15-20 min; repeat 0.5-1 g/kg q4-6h; watch for rebound
Hypertonic Saline (3%)	250 mL IV over 30 min	Can repeat; target Na 145-155 mEq/L
Hypertonic Saline (23.4%)	30 mL IV over 10-15 min	For impending herniation

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1️⃣4️⃣ POSTERIOR CIRCULATION STROKE

Clinical Features Suggesting Posterior Circulation

Symptom/Sign	Anterior	Posterior
Hemiparesis/hemiplegia	Common	May occur
Aphasia	Common (dominant)	Rare
Hemineglect	Common (non-dominant)	Rare
Vertigo/dizziness	Rare	Common
Diplopia	Rare	Common
Dysarthria	May occur	Common
Ataxia	Rare	Common
Visual field defect	Homonymous hemianopia	Bilateral blindness, hemianopia
Crossed deficits	Rare	Suggestive (ipsilateral face + contralateral body)
Decreased consciousness	Large infarcts	Common in basilar

Basilar Artery Occlusion

Feature	Details
Presentation	Coma, quadriplegia, locked-in syndrome
Prognosis without treatment	~90% mortality
Thrombolysis	Yes, if within window
Thrombectomy	Up to 24 hrs in selected patients (ATTENTION trial)
Key point	High suspicion needed; CTA essential

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1️⃣5️⃣ TRANSIENT ISCHEMIC ATTACK (TIA)

ABCD² Score

Factor	Finding	Points
Age	≥ 60 years	1
BP	SBP ≥ 140 OR DBP ≥ 90 at presentation	1
Clinical features	Unilateral weakness	2
	Speech impairment (without weakness)	1
	Other	0
Duration	≥ 60 min	2
	10-59 min	1
	< 10 min	0
Diabetes	Present	1

ABCD² Score	2-Day Stroke Risk	Management
0-3	1%	Outpatient workup may be considered
4-5	4%	Admit or expedited outpatient (24-48 hrs)
6-7	8%	Admit for urgent workup

TIA Workup (Complete Within 24-48 Hours)

Investigation	Purpose
CT or MRI Brain	Exclude infarct (DWI+ = not TIA; it's stroke)
CT Angiography or MR Angiography	Carotid stenosis; intracranial stenosis
Carotid Doppler	Extracranial carotid stenosis
ECG	Atrial fibrillation
Echocardiogram	Cardiac source (PFO, thrombus, valve)
Holter / Loop recorder	Paroxysmal AF
Lipid profile	Risk factor
HbA1c / Fasting glucose	Diabetes screening

TIA Treatment

Component	Recommendation
DAPT	Aspirin + Clopidogrel × 21 days (if not high bleed risk) → then single antiplatelet
Statin	High-intensity (Atorvastatin 40-80 mg)
BP control	Target < 130/80 after acute phase
Carotid revascularization	If ipsilateral carotid stenosis 50-99%: CEA or CAS within 2 weeks
Anticoagulation	If AF detected: start DOAC
Risk factor modification	Smoking cessation, exercise, diet, weight

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1️⃣6️⃣ STROKE UNIT CARE & NURSING PROTOCOLS

Key Elements of Stroke Unit Care

Element	Frequency/Details
Neurological observations	q1-4 hrs (GCS, pupils, limb power)
Vital signs	q1-4 hrs
Blood glucose monitoring	q6 hrs (more frequent if insulin)
Swallow screen	Before any PO intake
DVT prophylaxis	IPC from admission; pharmacological after 24-48 hrs
Positioning	Turn q2 hrs; affected limbs supported
Skin care	Pressure area care
Bladder care	Avoid indwelling catheter if possible
Nutrition	Dietitian review within 48 hrs
Mobilization	Early (within 24-48 hrs if stable)
Rehabilitation assessment	PT, OT, SLT within 24-48 hrs

Swallow Screening (Before Any Oral Intake)

Test	Method	Fail Criteria
Water swallow test	50 mL water in 10 mL aliquots	Coughing, wet voice, choking
If screen failed	NPO; SLT assessment	Insert NG tube for nutrition

DVT Prophylaxis

Timing	Intervention
Admission	Intermittent pneumatic compression (IPC)
24-48 hrs (ischemic)	Add LMWH if immobile and no hemorrhagic transformation
48-72 hrs (ICH)	Add LMWH if hematoma stable
Avoid	Graduated compression stockings (no benefit, risk of skin injury)

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1️⃣7️⃣ SECONDARY PREVENTION

Risk Factor Targets

Risk Factor	Target
Blood Pressure	< 130/80 mmHg (< 140/90 acceptable)
LDL Cholesterol	< 70 mg/dL (< 55 if very high risk)
HbA1c	< 7% (individualized)
Smoking	Complete cessation
Alcohol	≤ 2 drinks/day (men); ≤ 1 drink/day (women)
Exercise	≥ 150 min/week moderate intensity
Weight	BMI 18.5-24.9

Antithrombotic Therapy by Aetiology

Etiology	Acute Phase	Long-term Therapy	Notes
Large Artery Atherosclerosis	Aspirin 300 mg ± Clopidogrel (if minor stroke)	Clopidogrel 75 mg lifelong	Add high-intensity statin; consider carotid intervention
Small Vessel Disease (Lacunar)	Aspirin 300 mg ± Clopidogrel (if minor stroke)	Clopidogrel 75 mg lifelong	Strict BP control essential
Cardioembolic (AF)	Aspirin 300 mg initially	DOAC lifelong	No antiplatelet once on DOAC (unless other indication)
Cardioembolic (Mechanical Valve)	Aspirin 300 mg initially	Warfarin (INR 2.5-3.5) lifelong	DOAC contraindicated
Cardioembolic (Other – PFO, thrombus)	Aspirin 300 mg	Antiplatelet or anticoagulant based on source	Consider PFO closure if age < 60 with cryptogenic stroke
Cervical Artery Dissection	Aspirin 300 mg or Anticoagulation	Antiplatelet OR Anticoagulation × 3-6 months	No proven difference between the two
Hypercoagulable State	Anticoagulation	Anticoagulation (duration depends on cause)	Hematology input
Cryptogenic Stroke	Aspirin 300 mg ± Clopidogrel (if minor)	Clopidogrel 75 mg lifelong	Prolonged cardiac monitoring for occult AF

When to Start Anticoagulation in Cardioembolic Stroke (AF)

Stroke Severity	Timing to Start DOAC
TIA	Day 1-2
Minor stroke (NIHSS < 8)	Day 3-4
Moderate stroke (NIHSS 8-15)	Day 6-7
Severe stroke (NIHSS ≥ 16)	Day 12-14
Any stroke with hemorrhagic transformation	Delay further; individualize

📌 Repeat CT brain before starting anticoagulation in moderate-severe strokes to rule out hemorrhagic transformation

DOAC Selection for AF

DOAC	Dose (CrCl > 50)	Renal Adjustment
Apixaban	5 mg BD	2.5 mg BD if ≥2: age ≥80, weight ≤60 kg, Cr ≥1.5
Rivaroxaban	20 mg OD	15 mg OD if CrCl 15-50
Dabigatran	150 mg BD	110 mg BD if age >75 or CrCl 30-50; avoid if CrCl <30
Edoxaban	60 mg OD	30 mg OD if CrCl 15-50, weight ≤60 kg, or P-gp inhibitor

Carotid Revascularization

Stenosis (Symptomatic)	Recommendation
70-99%	CEA (or CAS if high surgical risk) within 2 weeks
50-69%	CEA may be considered (greater benefit in men, recent symptoms)
< 50%	Medical management

Stenosis (Asymptomatic)	Recommendation
≥ 70%	Individualized; CEA if life expectancy >5 yrs and low surgical risk
< 70%	Medical management

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1️⃣8️⃣ COMPLICATIONS OF STROKE

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1️⃣9️⃣ DISCHARGE PLANNING

Discharge Checklist

Category	Item
Medications	Antiplatelet/anticoagulant prescribed
	Statin prescribed
	Antihypertensives optimized
	Diabetes medications adjusted
Education	Stroke warning signs (FAST) explained
	Medication compliance emphasized
	Risk factor modification discussed
Referrals	Rehabilitation (inpatient or outpatient)
	Cardiac monitoring if cryptogenic
	PFO workup if indicated
	Carotid surgery if indicated
Follow-up	Neurology: 4-6 weeks
	Primary care: 1-2 weeks
	Carotid imaging: if stenosis

Discharge Medications

Drug Class	TIA / Minor Stroke (NIHSS ≤ 3)	Moderate-Severe Stroke (NIHSS > 3)	Duration
Antiplatelet	Aspirin 75 mg + Clopidogrel 75 mg (DAPT) × 21 days → then Clopidogrel 75 mg alone	Clopidogrel 75 mg alone (started after Aspirin 300 mg × 14 days in hospital)	Lifelong
OR Anticoagulant	DOAC (if AF) – no antiplatelet	DOAC (if AF) – no antiplatelet	Lifelong
Statin	Atorvastatin 40-80 mg	Atorvastatin 40-80 mg	Lifelong
Antihypertensive	Target < 130/80 mmHg; agent based on comorbidities	Target < 130/80 mmHg; agent based on comorbidities	Lifelong
Antidiabetic	As per glycemic control (HbA1c < 7%)	As per glycemic control (HbA1c < 7%)	As needed
PPI	Pantoprazole 40 mg (if on DAPT + high GI bleed risk)	Usually not needed (single antiplatelet)	Duration of DAPT

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2️⃣0️⃣ SPECIAL SCENARIOS

Stroke in Young Adults (< 50 years)

Additional Workup
Vasculitis screen (ESR, CRP, ANA, ANCA)
Hypercoagulability (Protein C, S, Antithrombin, Factor V Leiden, Prothrombin mutation)
Antiphospholipid antibodies
HIV, Syphilis testing
Drug screen (cocaine, amphetamines)
Cervical artery dissection imaging (MRA neck with fat suppression)
PFO/Septal defect workup (Bubble echo, TEE)
Consider genetic testing (CADASIL, Fabry, MELAS)

Pregnancy-Associated Stroke

Consideration	Details
Causes	Pre-eclampsia/eclampsia, CVST, Cardiomyopathy, Dissection
Imaging	MRI preferred (no radiation); CT if MRI unavailable
Thrombolysis	Relative contraindication; consider if life-threatening
Thrombectomy	May be performed
Antiplatelet	Aspirin safe
Anticoagulation	LMWH (DOACs contraindicated)

Wake-Up Stroke / Unknown Onset

Assessment	Purpose
MRI DWI-FLAIR mismatch	DWI+/FLAIR- suggests onset < 4.5 hrs
CT Perfusion	Identifies salvageable tissue

If Mismatch Present	Treatment
DWI-FLAIR mismatch	Thrombolysis may be considered (WAKE-UP trial)
CTP mismatch + LVO	Thrombectomy up to 24 hrs (DAWN/DEFUSE-3)

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📌 QUICK REFERENCE CARDS

🔴 PRIMARY CARE STROKE CHECKLIST

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🔵 STROKE CENTRE QUICK REFERENCE

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💊 THROMBOLYSIS QUICK DOSING

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⚠️ CRITICAL WARNINGS

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📊 KEY SCORES SUMMARY

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📚 ABBREVIATIONS

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