Hyperacute Management of Acute

Ischemic Stroke
: ‫االسم‬
: ‫مجموعة‬
Introduction to Acute Ischemic Stroke

medical_services Definition
Sudden loss of brain function due to interruption of blood flow to
a region of the brain

biotech Pathophysiology
• Thrombotic or embolic occlusion of cerebral artery
• Ischemic penumbra - salvageable tissue surrounding irreversibly
injured core
• Time-dependent neuronal death

timer Hyperacute Management

• Critical to restore blood flow as quickly as possible
• "Time is brain" - 1.9 million neurons lost per minute
• Reperfusion therapies can dramatically improve outcomes
Epidemiology and Impact of Acute Ischemic Stroke

795,000 87%
Strokes annually in the Are ischemic strokes
United States

5th $74B
Leading cause of death in the Annual economic burden
US

trending_up Global Impact

• Leading cause of long-term disability worldwide
• 1 in 4 adults over 25 will experience stroke in their lifetime
• 40% of stroke survivors have moderate to severe impairment
• 10% require care in a long-term facility
Pathophysiology of Acute Ischemic Stroke

biotech Ischemic Cascade

block water_drop bolt warning delete

Vessel Energy Ion Cytotoxic Cell
Occlusion Failure Pump Edema Death
Failure

grain Penumbra Concept

• Ischemic core: Irreversibly damaged tissue
• Ischemic penumbra: Tissue at risk but potentially salvageable
• Benign oligemia: Tissue with reduced blood flow but not at risk

timer Time-Dependent Injury

• 1.9 million neurons lost per minute
• 14 billion synapses destroyed per minute
• 12 km of myelinated fibers lost per hour

3h 6h 24h
Core expansion Penumbra reduction Final infarct
Clinical Presentation and Stroke Recognition

medical_services Common Stroke Symptoms

face Facial drooping accessibility_new Arm weakness

record_voice_over Speech difficulty visibility Vision changes

directions_walk Balance problems psychology Confusion

timer Importance of Early Recognition

• Time is brain - 1.9 million neurons lost per minute
• Early recognition → faster treatment → better outcomes
• Public education campaigns improve response times
• Prehospital notification improves ED preparation

emergency FAST Recognition Tool

F A S T
Face drooping Arm weakness Speech Time to call
difficulty
Prehospital Management and EMS Protocols

assignment Stroke Assessment Tools

LAPSS CPSS FAST

Los Angeles Cincinnati Facial droop, Arm
Prehospital Stroke Prehospital Stroke drift, Speech
Screen Scale problem

timer Critical Prehospital Information

schedule Last known well time - phone Prehospital notification -
determines treatment reduces door-to-needle time
eligibility

priority_high Overtriage - better than local_hospital Destination hospital - stroke-

undertriage for stroke capable facility

trending_up Impact of Prehospital Care

• EMS training improves stroke recognition by 40%
• Prehospital notification reduces door-to-needle time by 15-30
minutes
• Direct transport to stroke centers doubles thrombolysis rates
• Mobile stroke units can treat patients in the field
Stroke Systems of Care

architecture Effective Stroke System Components

Primary & Secondary Public & Professional

health_and_safety Prevention school Education

Hyperacute & Acute

emergency EMS Response & Protocols local_hospital Treatment

accessible Rehabilitation Services analytics Quality Measures & Evaluation

trending_up Benefits of Organized Stroke Care

• Reduced mortality by 20% in stroke units
• Increased thrombolysis rates by 2-3 times
• Improved functional outcomes and reduced disability
• Shorter hospital stays and lower costs

linear_scale Stroke Care Continuum

shield emergency local_hospital healing home

Prevention Prehospital Acute Care Rehabilitation Community
Primary and Comprehensive Stroke Centers

local_hospital Stroke Center Designations

Primary Stroke Comprehensive

medical_services Center (PSC) healing Stroke Center (CSC)
check_circle IV thrombolysis capability check_circle All PSC capabilities
check_circle 24/7 stroke team check_circle Endovascular therapy
check_circle Neuroimaging services check_circle Neurosurgical services
check_circle Neurosurgical check_circle Neurointensive care
consultation
check_circle Advanced imaging
check_circle Stroke registry (MRI/CTA)

verified Certification & Impact

• The Joint Commission began certifying PSCs in 2003, CSCs in
2012
• Over 900 PSCs certified in the US
• PSC admission associated with increased thrombolysis and
reduced mortality
• Longer certification duration correlates with better outcomes

Routing protocols direct patients to the most appropriate

stars facility based on stroke severity, time window, and distance to
stroke centers
Emergency Department Assessment

medical_services Initial Stabilization

favorite ABCs monitor_heart Vital Signs

Airway, Breathing, BP, HR, RR, Temp, O₂ Sat
Circulation

bloodtype IV Access medication Medications

Two large-bore IVs Aspirin, glucose if needed

psychology Neurological Examination

NIH Stroke Scale (NIHSS)

• Standardized assessment of stroke severity

assessment • 11 items scoring 0-42 (higher = worse)

• Predicts outcomes and treatment eligibility
• Should be completed within 10 minutes

science Laboratory Tests

• Point-of-care glucose - immediate result
• CBC, CMP, coagulation studies
• Cardiac enzymes (if indicated)
• Type and screen (for potential thrombolysis)
Neuroimaging in Hyperacute Stroke

image Non-contrast CT Findings

• Hyperdense MCA sign - thrombus visualization
• Early ischemic changes (loss of gray-white differentiation)
• Sulcal effacement
• Excludes hemorrhage before thrombolysis

assessment ASPECTS Score

Alberta Stroke Program Early CT Score

• 10-point scale (0-10) evaluating MCA territory

calculate • Lower scores = larger ischemic changes

• Score ≥6 generally favorable for thrombectomy
• Predicts outcomes and treatment response

compare Imaging Modalities Comparison

photo_camera CT biotech MRI

schedule Fast (5 min) schedule Longer (15-20 min)
accessibility Widely available warning Limited availability
check_circle Excludes hemorrhage check_circle Higher sensitivity
warning Limited early sensitivity check_circle DWI shows early ischemia
Advanced Imaging in Hyperacute Stroke

compare Advanced Imaging Modalities

timeline CTA grain CTP

check_circle Identifies vessel check_circle Measures cerebral blood
occlusion flow
check_circle Assesses collateral check_circle Identifies perfusion deficit
circulation
check_circle Quantifies tissue at risk
check_circle Guides thrombectomy
planning

pie_chart Core vs. Penumbra Concept

Tissue Viability Assessment

• Ischemic core: Irreversibly damaged tissue (CBF <30%)

bubble_chart • Penumbra: At-risk but salvageable tissue (Tmax >6s)

• Mismatch: Penumbra larger than core
• Treatment decisions based on core/penumbra ratio

schedule Time Window Extension

• Advanced imaging enables extended treatment windows
• Patients with favorable mismatch may benefit up to 24 hours
• Perfusion imaging guides patient selection beyond standard
time windows
• RAPID automated processing improves decision-making speed
Time Windows for Treatment

schedule Treatment Time Windows

medication IV Thrombolysis Mechanical

build Thrombectomy
Standard
0-3h window Standard
Extended
0-6h window
3-4.5h window Extended
Perfusion 6-24h window with
4.5-24h imaging imaging
selection Under
>24h investigation

psychology "Time is Brain"

Neuronal Loss Per Minute

Every minute of ischemia results in irreversible brain
damage

timer 1.9M 14B 12km

Neurons lost Synapses Myelin fibers
destroyed lost/hour

speed Key Time Metrics

• Door-to-needle < 60 minutes for IV thrombolysis
• Door-to-puncture < 90 minutes for thrombectomy
• Onset-to-treatment directly correlates with outcomes
• Every 15-minute delay reduces likelihood of good outcome
Intravenous Thrombolysis

medication Thrombolytic Agents

history Alteplase trending_up Tenecteplase

science Recombinant tissue science Genetically modified tPA
plasminogen activator
schedule Single bolus (5-10
schedule 60-minute infusion seconds)
monitor_weight 0.9 mg/kg (10% bolus, monitor_weight 0.25 mg/kg (single bolus)
90% infusion)
thumb_up Superior to alteplase in
timer Standard of care for 25+ trials
years

biotech Mechanism of Action

• Converts plasminogen to plasmin
• Plasmin degrades fibrin in thrombus
• Restores blood flow to ischemic brain tissue
• Most effective when administered early

new_releases Recent Advances

Extended Time Window

• Perfusion imaging selection up to 24 hours
lightbulb • Tenecteplase shows 3% absolute benefit over alteplase
• NNT of 33 for achieving no disability
• Facilitates transport for thrombectomy
Patient Selection for Thrombolysis

fact_check Selection Criteria

check_circle Inclusion Criteria cancel Exclusion Criteria

schedule Onset < 4.5 hours bloodtype Intracranial hemorrhage
psychology Measurable neurological schedule Symptom onset > 4.5
deficit hours
image No hemorrhage on CT/MRI healing Recent surgery/trauma (<
3 months)
person Age ≥ 18 years
monitor_heart Uncontrolled
hypertension (>185/110)

warning Absolute Contraindications

• Intracranial hemorrhage on imaging
• Subarachnoid hemorrhage
• Recent intracranial surgery or serious head trauma
• Known bleeding diathesis (INR > 1.7, platelets < 100,000)
• Active internal bleeding

priority_high Special Considerations

Clinical Decision Points

• Mild stroke (NIHSS < 5): Limited benefit, consider

lightbulb antiplatelets
• Wake-up stroke: Use perfusion imaging for selection
• Large vessel occlusion: Consider direct thrombectomy
• Pregnancy: Consider benefits vs. risks
Mechanical Thrombectomy

build Device Evolution

First Generation
Second Generation
history Merci Retrieval System
(2004)
trending_up Stent Retrievers (2012)

Current
Future
new_releases Stent Retrievers +
Aspiration
lightbulb Distal Access Devices

science Techniques
• Stent retriever - Captures clot in stent-like device
• Aspiration - Direct suction of thrombus
• Combined approach - Solumbra technique
• Distal access - Smaller vessels (M2/M3)

analytics Evidence & Outcomes

Landmark Trials (2015)

• MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT
• NNT 3-4 for functional independence

verified
• TICI 2b/3 reperfusion in 71-88% of cases

46% 15% 24h

Functional Mortality Extended window
independence reduction
Patient Selection for Thrombectomy

fact_check Selection Criteria

image Imaging Criteria person Clinical Criteria

check_circle ASPECTS ≥6 (0-10 scale) check_circle NIHSS ≥6 (moderate-
severe)
check_circle Large vessel occlusion
(ICA/M1/M2) check_circle Age 18-90 years
check_circle Perfusion mismatch (core < check_circle Premorbid mRS 0-2
penumbra)
check_circle No contraindications to
check_circle Good collateral circulation angiography

science Extended Window Trials

DAWN Trial DEFUSE 3 Trial

• 6-24 hours from onset • 6-16 hours from onset
• Clinical-core mismatch • Perfusion mismatch
• Age ≥80: NIHSS ≥10 + core • Core <70mL
<21mL • Penumbra ≥15mL
• Age <80: NIHSS ≥10 + core • Mismatch ratio ≥1.8
<31mL
• OR NIHSS ≥20 + core <51mL

priority_high Special Considerations

• Posterior circulation strokes (basilar artery occlusion)
• Mild strokes with large vessel occlusion (ongoing trials)
• Distal vessel occlusions (M2/M3 segments)
• Wake-up strokes with favorable imaging profile
Blood Pressure Management in Hyperacute Stroke

monitor_heart Blood Pressure Targets

With Without With

medication Thrombolysis healing Thrombolysis build Thrombectomy

<185/110 <220/120 <140/90

mmHg mmHg mmHg
Maximum BP before Permissive Post-procedure target
treatment hypertension

science Evidence from Trials

Key Trial Findings

• ENCHANTED: Intensive BP lowering (130-140 mmHg) reduced ICH but no
functional benefit

analytics • CATIS: Immediate BP reduction in non-thrombolysed patients did not

reduce death/disability
• BEST: Prehospital GTN did not improve functional outcome
• Excessive BP lowering may worsen cerebral ischemia

medication Antihypertensive Options

pill Labetalol pill Nicardipine pill Clevidipine

pill Hydralazine pill Enalaprilat

pill Sodium Nitroprusside

Management of Other Physiological Parameters

monitor_heart Key Physiological Parameters

thermostat Temperature
water_drop Blood Glucose
• Treat hyperthermia • Maintain 5-15 mmol/L
>38°C • Monitor closely to avoid
• Use antipyretics hypoglycemia
• Induced hypothermia • Avoid aggressive
not routinely glucose control
recommended

air Oxygenation
opacity Hydration
• Supplemental O₂ only if • Ensure adequate
Sat <95% IV/oral fluids
• No benefit to routine O₂ • Maintain normal
supplementation hydration status
• Hyperbaric O₂ not • Avoid dehydration
recommended

accessibility_new Positioning & Mobility

• Individualized approach for head positioning
• Consider lying flat vs. head elevation >30° in first 24 hours
• Early mobilization when medically stable
• Swallow assessment before oral intake

bloodtype Venous Thromboembolism Prevention

VTE Prevention Strategies

• Intermittent pneumatic compression within 3 days

health_and_safety • Continue for 30 days or until mobile/discharge

• Avoid routine LMWH or compression stockings
• Consider anticoagulation after 24 hours if no
contraindication
Post-Treatment Care and Monitoring

monitor_heart Acute Monitoring

psychology Neurological
favorite Cardiovascular
• NIHSS every 4 hours • BP monitoring every
• Monitor for 15-60 min
deterioration • Cardiac rhythm
• Assess for hemorrhagic monitoring
transformation • Maintain perfusion

image Imaging
medication Medications
• 24-hour follow-up • Antiplatelet therapy
CT/MRI after 24h
• Assess for hemorrhage • Statin therapy
• Evaluate infarct size • Anticoagulation if
indicated

healing Stroke Unit Care

• Multidisciplinary team approach
• Early mobilization and rehabilitation
• Swallow assessment before oral intake
• Dysphagia screening and management

shield Secondary Prevention

Key Prevention Strategies

• Antiplatelet therapy (aspirin, clopidogrel)

health_and_safety • Statin therapy regardless of baseline cholesterol

• Blood pressure control (<140/90 mmHg)
• Lifestyle modifications (diet, exercise, smoking cessation)
• Carotid intervention if significant stenosis
Complications and Outcomes

warning Common Complications

bloodtype Hemorrhagic
Transformation
water_drop Cerebral Edema
• Peaks at 3-5 days
• Symptomatic ICH: 2-7% • Can cause mass effect
with thrombolysis • May require osmotic
• More common with therapy
larger infarcts
• Risk increases with
delayed treatment

sync_problem Recurrent Stroke

coronavirus Medical
Complications
• Early recurrence: 1-4%
in 90 days • Infections (pneumonia,
• Higher with UTI)
cardioembolic source • Deep vein thrombosis
• Reduced with • Cardiac complications
secondary prevention

analytics Functional Outcomes

Outcome Measures
• mRS 0-2 (functional independence): 40-50%
• Mortality at 90 days: 15-20%
• Better outcomes with earlier treatment
• Thrombectomy improves outcomes by 15-20%

trending_up 46% 30% 15%

Functional Functional Mortality
independence independence reduction with
with with thrombolysis thrombectomy
thrombectomy

psychology Prognostic Factors

• Age and baseline functional status
• Stroke severity (NIHSS score)
• Infarct size and location
• Time to treatment
• Successful reperfusion (TICI 2b/3)
Future Directions in Hyperacute Stroke Care

update Emerging Therapies

schedule Extended Time

Windows
science New Thrombolytics
• Tenecteplase replacing
• >24 hour windows alteplase
under investigation • Novel agents targeting
• Advanced imaging thrombus components
selection • Combination therapies
• Individualized
treatment approaches

biotech Adjuvant Therapies

build Device Innovation
• DNase for DNA-rich • Distal access devices
thrombi • Combined
• Von Willebrand factor aspiration/stent
antagonists retrievers
• Alpha-2-antiplasmin • Robotics in
inhibitors thrombectomy

local_shipping Prehospital Innovation

• Mobile stroke units with CT capability
• Ambulance-based thrombolysis
• AI-powered stroke detection
• Drone delivery of medications to remote areas

computer Digital Health & Telemedicine

Remote Stroke Care

• Telestroke networks expanding globally
connect_without_contact • AI-assisted imaging interpretation
• Virtual reality for rehabilitation
• Wearable devices for continuous monitoring
Summary and Key Points

stars Critical Elements of Hyperacute Stroke Care

timer Time is Brain

architecture Organized Systems
• 1.9M neurons lost per • Stroke centers improve
minute outcomes
• Earlier treatment = • Prehospital protocols
better outcomes • Regional networks
• Extended windows with
imaging

image Appropriate Imaging

healing Evidence-Based
Treatment
• Rapid CT to exclude
hemorrhage • IV thrombolysis
• CTA for vessel occlusion (alteplase/tenecteplase)
• Perfusion for tissue • Mechanical
viability thrombectomy for LVO
• Physiological
parameter management

trending_up Future Directions

• Extended treatment windows with advanced imaging
• Novel thrombolytics and adjuvant therapies
• Mobile stroke units and telemedicine expansion
• Artificial intelligence for stroke detection and triage

Key References
1. Campbell BCV, et al. Hyperacute ischemic stroke care—Current treatment
and future directions. Int J Stroke. 2024.
2. Bhalla A, et al. An update on hyper-acute management of ischaemic stroke.
Br J Hosp Med (Lond). 2021.
3. Song S, et al. Hyperacute Management of Ischemic Stroke. Semin Neurol.
2014.