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Acute Ischemic Stroke (CVA) - CCS Case Guide

Key Takeaway: Acute ischemic stroke requires emergent evaluation and treatment within narrow time windows. IV alteplase within 4.

Acute ischemic stroke requires emergent evaluation and treatment within narrow time windows. IV alteplase within 4.5 hours and mechanical thrombectomy within 24 hours for large vessel occlusions can dramatically improve outcomes. CCS cases heavily test time-sensitive decision-making.

Recognizing the Stroke Presentation

  • History: Acute onset of focal neurological deficits: hemiparesis, facial droop, speech difficulty, vision changes, with a clear time of symptom onset
  • Physical Exam: Unilateral weakness, facial droop, aphasia or dysarthria, visual field cuts, ataxia, hemisensory loss; NIHSS assessment
  • Vital Signs: Often hypertensive (permissive hypertension up to 220/120 if no tPA); may have irregular rhythm (atrial fibrillation)

Immediate Actions (First 5 Minutes)

These orders should be placed immediately — timing is scored:

Critical First Orders

  • ✓ Activate stroke code
  • ✓ Non-contrast CT head STAT (rule out hemorrhage)
  • ✓ Check fingerstick glucose
  • ✓ Establish time of onset or last known well
  • ✓ NIHSS assessment
  • ✓ IV access, continuous telemetry, NPO

Complete Workup

After initial stabilization, complete the diagnostic workup:

  • Non-contrast CT head (emergent)
  • CT angiography head and neck (for large vessel occlusion)
  • CT perfusion (if within thrombectomy window)
  • CBC, BMP, coagulation studies (PT/INR)
  • Fingerstick glucose
  • Troponin
  • ECG (rule out atrial fibrillation)
  • Lipid panel
  • Hemoglobin A1c
  • Echocardiogram (TTE, consider TEE)
  • MRI brain with diffusion-weighted imaging (if diagnosis uncertain)

Treatment

Thrombolytics

  • IV alteplase 0.9 mg/kg (max 90 mg) if within 4.5 hours of onset
  • 10% as bolus, remainder infused over 60 minutes
  • BP must be < 185/110 before and < 180/105 after tPA
  • No anticoagulants or antiplatelets for 24 hours post-tPA

Thrombectomy

  • Consider mechanical thrombectomy for large vessel occlusion within 24 hours
  • Requires CT angiography or MR angiography confirmation
  • Can be performed in addition to IV tPA

Blood Pressure

  • Pre-tPA: lower to < 185/110 with IV labetalol or nicardipine
  • Post-tPA: maintain < 180/105 for 24 hours
  • No tPA: permissive hypertension up to 220/120

Secondary Prevention

  • Aspirin 325 mg within 24-48 hours (after tPA window)
  • High-intensity statin (atorvastatin 80 mg)
  • Anticoagulation for atrial fibrillation (after acute phase)
  • DVT prophylaxis with SCDs (hold heparin 24 hours post-tPA)

Common Pitfalls

Scoring Tip: These are the most commonly missed actions for Stroke cases.

  • Delaying CT head and tPA administration
  • Giving tPA outside the 4.5-hour window or with contraindications
  • Not checking glucose (hypoglycemia mimics stroke)
  • Giving antiplatelet or anticoagulant within 24 hours of tPA
  • Aggressively lowering BP in non-tPA candidates
  • Forgetting swallow evaluation before oral intake

Disposition

  • Admit to stroke unit or neuro ICU
  • Neuro checks every 1-2 hours for first 24 hours
  • Repeat CT head at 24 hours or with any neurological change
  • PT/OT/Speech therapy evaluations
  • Discharge with secondary prevention medications and neurology follow-up

Key Orders Checklist

  • ☐ Non-contrast CT head STAT
  • ☐ CT angiography head and neck
  • ☐ IV alteplase (if eligible)
  • ☐ Continuous telemetry and neuro checks
  • ☐ NPO until swallow evaluation
  • ☐ Aspirin 325 mg (after tPA window)
  • ☐ Atorvastatin 80 mg

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