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Neurology · Topic 1 of 22

Acute Ischemic Stroke

Neurology · cerebrovascular

Acute Ischemic Stroke

Time is brain: thrombolysis within 4.5 hours of last known well, thrombectomy for large-vessel occlusion up to 24 hours, and BP under 185/110 first.

Key numbers
IV thrombolysis within 4.5 hours≤ 4.5 h from LKW
BP under 185/110 before lytics< 185/110 → < 180/105
Thrombectomy for LVO up to 24 hoursEVT ≤ 24 h
01 · GiveIV thrombolysis within 4.5 hours

For a disabling deficit within 4.5 hours of last known well, give tenecteplase 0.25 mg/kg bolus (max 25 mg) or alteplase 0.9 mg/kg (max 90 mg); don't wait for CTA or perfusion imaging.

02 · Defined byBP under 185/110 before lytics

Lower BP to < 185/110 mmHg before thrombolysis and keep it < 180/105 mmHg for 24 hours after; do not target SBP < 140 — no benefit after lytics and harm after successful thrombectomy.

03 · DoThrombectomy for LVO up to 24 hours

Order CTA for suspected large-vessel occlusion; thrombectomy is recommended for ICA or M1 occlusion with NIHSS ≥ 6 within 6 hours, and for selected patients at 6–24 hours, including large cores (ASPECTS 3–5).

01

Do right now

In this order
First moves
1
Last known well starts every window
→
2
Noncontrast CT and fingerstick glucose first
→
3
BP under 185/110 before lytics< 185/110 → < 180/105
→
4
IV thrombolysis within 4.5 hours≤ 4.5 h from LKW
→
5
Thrombectomy for LVO up to 24 hoursEVT ≤ 24 h
Why each step
Last known well starts every windowReperfusion windows run from last known well — the last time the patient was seen at baseline — not from discovery; a patient who wakes with deficits was last known well at bedtime.
Noncontrast CT and fingerstick glucose firstGet a noncontrast head CT (or MRI) to exclude hemorrhage and a bedside glucose before thrombolysis; glucose must be above 50 mg/dL, because hypoglycemia is a classic stroke mimic.
BP under 185/110 before lyticsLower BP to < 185/110 mmHg before thrombolysis and keep it < 180/105 mmHg for 24 hours after; do not target SBP < 140 — no benefit after lytics and harm after successful thrombectomy.
IV thrombolysis within 4.5 hoursFor a disabling deficit within 4.5 hours of last known well, give tenecteplase 0.25 mg/kg bolus (max 25 mg) or alteplase 0.9 mg/kg (max 90 mg); don't wait for CTA or perfusion imaging.
Thrombectomy for LVO up to 24 hoursOrder CTA for suspected large-vessel occlusion; thrombectomy is recommended for ICA or M1 occlusion with NIHSS ≥ 6 within 6 hours, and for selected patients at 6–24 hours, including large cores (ASPECTS 3–5).
02

Management

Orders
No reperfusion: treat only BP ≥ 220/120Patients not receiving reperfusion get permissive hypertension: treat only BP ≥ 220/120 mmHg (or another end-organ indication), lowering it about 15% over the first 24 hours.
Aspirin plus clopidogrel 21 days after minor strokeAfter minor noncardioembolic stroke without lytics, give aspirin plus clopidogrel for 21 days, then one agent; for atherosclerotic causes the 2026 guideline extends this to NIHSS 4–5 and starts up to 72 hours.
Aspirin within 48 hours if no lyticsPatients who do not receive thrombolysis get aspirin 81–325 mg within 48 hours; after thrombolysis, hold antiplatelets and anticoagulants for 24 hours.
Glucose 140–180; avoid tight controlKeep glucose about 140–180 mg/dL and treat values < 60 mg/dL; intensive insulin to 80–130 mg/dL is not recommended — no functional benefit and more severe hypoglycemia.
Oxygen only to keep SpO₂ above 94%Give supplemental oxygen only when needed to keep SpO₂ > 94%; treat temperature > 38 °C with antipyretics and look for the source.
Swallow screen before anything by mouthScreen for dysphagia before any food, fluids or oral medications to prevent aspiration; start enteral nutrition within 7 days if the patient cannot swallow safely.
Pneumatic compression for immobile patientsUse intermittent pneumatic compression for DVT prophylaxis in immobile stroke patients; prophylactic low-molecular-weight heparin may be added when there is no contraindication.
03

Red flags & don'ts

Avoid harm
Thrombolysis exclusions: bleed, recent stroke, coagulopathy avoidClassic exclusions: any intracranial hemorrhage, ischemic stroke or severe head trauma within 3 months, intracranial or spinal surgery within 3 months, active internal bleeding, GI bleeding within 21 days, platelets < 100,000/mcL, INR > 1.7.
DOAC within 48 h: lytics usually withheld avoidClassic rule: withhold thrombolysis after a DOAC dose within 48 hours unless anticoagulant-effect tests are normal; the 2026 guideline modified the approach to contraindications, so decide case by case with the stroke team.
Malignant MCA edema: consider decompressive hemicraniectomy complicationLarge hemispheric infarcts swell most at 48–72 hours; for neurologic deterioration, consult neurosurgery for decompressive craniectomy, which saves lives but is less certain to help at age 60 or older.
Swollen cerebellar infarct: suboccipital decompression complicationA swollen cerebellar infarct compresses the brainstem and fourth ventricle; deterioration calls for suboccipital decompressive craniectomy — a ventriculostomy alone risks upward herniation.
04

The rules

Know these
Non-disabling minor stroke: DAPT, not lyticsFor mild non-disabling deficits (for example, isolated sensory loss) within 4.5 hours, do not give thrombolysis — dual antiplatelet therapy is preferred; a disabling deficit gets lytics regardless of NIHSS.
05

IV thrombolysis or thrombectomy?

Commonly confused
WhoAny eligible patient with a disabling deficit
Standard window≤ 4.5 h from last known well
Extended window4.5–9 h with perfusion or DWI–FLAIR mismatch
Imaging before treatmentNoncontrast CT (no CTA needed)
SeverityDisabling, regardless of NIHSS
06

More detail

Reference
Show 7 reference facts
Thrombolysis may be reasonable 4.5–9 hours from last known well (or within 9 hours of the midpoint of sleep) with salvageable penumbra on automated perfusion imaging, or with DWI–FLAIR mismatch on MRI.
Basilar artery occlusion with NIHSS ≥ 10, prestroke mRS 0–1 and PC-ASPECTS ≥ 6: thrombectomy within 24 hours is now strongly recommended.
When a patient qualifies for both, give IV thrombolysis and proceed to thrombectomy — do not skip lytics for thrombectomy alone; never delay CTA to wait for a creatinine.
A baseline ECG and troponin are recommended in suspected stroke but must not delay thrombolysis or thrombectomy.
In AF-related stroke, early oral anticoagulation is reasonable for carefully selected (milder) strokes; otherwise acute anticoagulation is avoided because of hemorrhagic transformation risk.
Stroke mimics: seizure with postictal (Todd) paralysis, hypoglycemia, hemiplegic migraine, CNS infection and functional disorders; thrombolysis given to a mimic carries a very low (about 0.5%) brain hemorrhage risk.
Adjunctive antithrombotics with thrombolysis (argatroban, eptifibatide) and tirofiban before thrombectomy show no benefit and are not recommended.
Pearl

"Last known well," not "found down," starts the clock — and every minute to reperfusion costs brain.

Sources · Prabhakaran S et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke (AHA/ASA). Stroke 2026 — abstract via Europe PMC · emDocs — 2026 Guideline Update: Early Management of Acute Ischemic Stroke (Jan 2026) · Guideline Central — Feb 2026 AHA/ASA Early Management of AIS Guideline Spotlight (10 take-home messages) · Practical Neurology — Guidelines for the Management of Acute Ischemic Stroke Published (2026) · Merck Manual Professional — Ischemic Stroke (updated Jan 2026) · Blood pressure management in stroke: comparative review of the 2025 AHA/ACC, 2024 ESC, 2023 ESH and 2025 JSH guidelines. Hypertens Res 2026 · HelixTalk 196 (Rosalind Franklin University) — review of the 2026 acute ischemic stroke guidelines · Wijdicks EFM et al. Recommendations for the management of cerebral and cerebellar infarction with swelling (AHA/ASA statement). Stroke 2014 — abstract via Europe PMC · Kleindorfer DO et al. 2021 AHA/ASA Guideline for the Prevention of Stroke in Patients With Stroke and TIA. Stroke 2021;52:e364–e467 (full-text PDF copy) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).