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Initial Management of Stroke
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Non-contrast CT to triage ischemic vs hemorrhagic.
Decision
Outcome
Decision
Acute stroke symptoms. First three steps?
✓
ABCs → non-contrast CT head → labs (glucose, coags, CBC, BMP)
✗
MRI brain before anything else
✗
Immediate IV tPA empirically
Decision
CT result?
✓
No hemorrhage → ischemic pathway
✓
Hemorrhage seen → hemorrhagic pathway
Decision
Ischemic stroke. Eligibility for reperfusion?
✓
Within 4.5 h of LKW and no contraindications → IV alteplase or tenecteplase
✓
Large-vessel occlusion within 24 h → endovascular thrombectomy (consider in addition to lytics)
✓
Beyond windows → permissive hypertension (treat BP only if >220/120), dual antiplatelet, statin
Outcome
IV thrombolytic; keep BP <185/110 before and <180/105 for 24 h after
Outcome
Endovascular thrombectomy for proximal anterior circulation occlusion
Up to 24 h with favorable imaging (DAWN, DEFUSE-3 criteria).
Outcome
Permissive HTN + dual antiplatelet (ASA + clopidogrel for 21–90 d in minor stroke), high-intensity statin
Outcome
Reverse anticoagulation; BP control to systolic 140–160; maintain normal ICP
Neurosurgery consult; consider hematoma evacuation for cerebellar bleeds >3 cm or rapidly worsening.
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