Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Acute Ischemic Stroke

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In one line

·A clot plugs an artery inside the brain, cutting off oxygen; the brain cells fed by that artery start dying within minutes because the brain has no backup fuel tank.

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Normal physiology

·The brain has zero fuel reserve and depends second by second on fresh blood arriving through four main pipes: two carotid arteries running up the front of the neck and two vertebral arteries climbing the back. These four pipes meet at the base of the brain and join into a backup ring called the circle of Willis, then branch out into smaller and smaller vessels that reach every patch of brain tissue.

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What goes wrong

·A blood clot gets stuck inside one of the brain arteries. The tissue directly downstream loses its blood supply in seconds. Around that dead center sits a border zone (called the penumbra) where cells are stunned and barely hanging on, kept alive by tiny backup vessels that reroute a trickle of blood from nearby. That border zone can still be saved if blood flow comes back fast enough.

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Hallmark signs

·Sudden face droop on one side
·Sudden arm or leg weakness on one side
·Slurred speech or trouble finding words
·Loss of vision on one side in both eyes
·Sudden dizziness, loss of balance, or trouble walking
·Sudden severe headache unlike any before
·Confusion or decreased alertness
·Double vision or trouble swallowing

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Red flags · escalate now

·Sudden severe headache with the deficit—may be bleeding in the brain instead of a clot; get an emergency CT scan immediately before giving any blood thinner
·Neurologic symptoms getting rapidly worse after starting tPA—suggests bleeding inside the skull from the clot-buster; stop the infusion, repeat CT right away, and reverse the medicine with clotting factors and platelets
·Coma with tiny pinpoint pupils—basilar artery stroke cutting off blood to the brainstem; very high risk of death; secure the airway and consider emergency thrombectomy to pull the clot out
·Blood pressure above 185/110 before giving tPA—too high increases bleeding risk; must lower it carefully with IV medicine like labetalol or nicardipide before starting the clot-buster
·Seizure at the moment stroke symptoms start—raises the chance the clot will turn into bleeding later; confirm with imaging before giving reperfusion therapy

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Workup

·Non-contrast CT scan of the head
·CT angiography of the head and neck
·CT blood flow (perfusion) or MRI with diffusion-weighted imaging and FLAIR sequences
·Fingerstick blood glucose
·12-lead electrocardiogram and continuous heart-rhythm monitor (telemetry)
·PT, INR, platelet count, and basic metabolic panel
·Troponin

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Treatment

·IV alteplase (tPA) 0.9 mg per kilogram of body weight, maximum dose 90 mg, given within 4.5 hours of last-known-well time
·IV tenecteplase 0.25 mg per kilogram (maximum 25 mg) as a single push over 5 seconds, within 4.5 hours
·Mechanical thrombectomy: threading a catheter up through the groin artery into the brain, then using a tiny cage (stent retriever) or suction tube to pull the clot out
·Let blood pressure run high: systolic up to 220 mmHg and diastolic up to 120 mmHg before reperfusion
·Aspirin 325 mg by mouth, started 24 to 48 hours after tPA (or right away if no tPA was given)
·High-intensity statin: atorvastatin 80 mg or rosuvastatin 40 mg once daily, started in the hospital
·Oral anticoagulation with apixaban, rivaroxaban, edoxaban, or dabigatran if atrial fibrillation (an irregular, quivering heartbeat) is confirmed

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NCLEX trap

·Wait for the brain CT scan (a picture that shows bleeding) first. If the stroke is caused by bleeding instead of a clot, aspirin makes the bleeding worse. Also, after tPA (the clot-busting medicine), no aspirin or any blood thinner for 24 hours — the brain tissue is fragile and bleeds easily.
·Let blood pressure stay high (up to 220/120 mmHg) unless you plan to give tPA. The high pressure pushes blood through smaller backup routes (collateral vessels) to feed the struggling brain tissue around the dead zone (the penumbra). Only bring blood pressure below 185/110 mmHg if tPA will be given, because tPA plus very high pressure raises bleeding risk.
·Keep the patient NPO (nothing by mouth) until a swallow test is done and passed. Stroke can damage the swallow muscles without obvious signs — food or liquid can slip into the lungs (aspiration) and cause pneumonia or choking.
·When a big artery is blocked (large vessel blockage (occlusion) or LVO), the catheter procedure is the single best treatment and works up to 24 hours in the right patients. Call the thrombectomy team right away — do both treatments at the same time, not one after the other. Studies prove thrombectomy saves more brain and function than tPA alone for LVO.
·The first 24 hours after tPA are the most dangerous. The damaged brain tissue can start bleeding (hemorrhagic transformation). Keep blood pressure below 180/105 mmHg and check the patient's neuro exam every 15 minutes at first, then every 30 minutes for 6 hours, then hourly until 24 hours.

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