Ischemic Stroke

 BP goal

TPA yes, no - 

TPA prior or after

no TPA  

On AC

Yes TPA TPA prior < 185 / 110

Yes TPA After TPA < 180 / 105 for 24 hours

no TPA permissive htn < 220 / 120 drop 20 per day

on AC SBP  < 180

Rationale - if you give TPA you increase risk of bleeding, you want to have lower blood pressure 185/110 and 180 / 105

if you don't give TPA you can have higher blood pressure 220 / 120 drop by 20 per day

NIHSS, LKW

- no candidate for tPA, on NOAC, LKW >4.5 Hrs, INR >1.7

- ACBD2 (risk for stroke after TIA)

- CTH

- CT neuroperfusion

- CT COW

- MRI per neuro

- ECHO with bubble study per neuro

- Aspirin, Plavix, Statin

- Neuro checks per protocol

- PT/OT/ST

- Lipid panel, HgbA1c, TSH

BP management goals in acute ischemic stroke: Current AHA guidelines recommend antihypertensive medications should be withheld for the first 24 hours after stroke unless the SBP is >220 or the DBP is >120.  A reasonable goal is to lower blood pressure by 15% during the first 24 hours after onset of stroke.  BP should be gently normalized thereafter. Individual patient acute/active co-morbidities may modify these treatment guidelines.  We will leave this to your discretion.

ABCD 2 score - Estimates the risk of stroke after a suspected transient ischemic attack (TIA).

Per the validation study, 0-3 points: Low Risk

2-Day Stroke Risk: 1.0%

7-Day Stroke Risk: 1.2%

90-Day Stroke Risk: 3.1%