Compare conditions

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

Stroke Window

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In one line

·A clot is blocking an artery in the brain, killing brain tissue minute by minute.

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Normal physiology

·The brain is fed by a network of arteries — the internal carotid arteries split into the anterior cerebral artery (ACA, which feeds the leg strip on top of the brain) and the middle cerebral artery (MCA, which feeds the face, arm, and language centers on the side). The vertebral arteries join to form the basilar artery, which splits into the posterior cerebral arteries (PCA, feeding the vision centers in the back). Autoregulation keeps blood flow steady: when blood pressure drops, the arteries widen; when pressure rises, they tighten. Collateral vessels (tiny backup loops, like the circle of Willis at the base of the brain and pial collaterals on the surface) can sometimes reroute blood around a blockage and keep tissue alive downstream.

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What goes wrong

·A clot suddenly blocks one of the brain's arteries, cutting off oxygen to everything downstream.

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Hallmark signs

·Sudden weakness or numbness on one side of the face, arm, or leg
·Sudden trouble speaking or slurred speech
·Sudden vision loss or blurred vision in one or both eyes
·Sudden severe headache with no clear cause
·Sudden dizziness, loss of balance, or trouble walking
·Sudden confusion or trouble understanding what is happening
·Face droop on one side (one side of the smile sags)
·Arm drift (one arm drifts downward when both arms are held out)

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Red flags · escalate now

·Symptoms started less than 24 hours ago (the treatment window is still open—this is a medical emergency)
·Sudden severe headache, vomiting, or decreased alertness (may signal bleeding in the brain)
·Blood pressure over 185/110 mm Hg (high pressure raises the risk of bleeding if clot-busting medicine is given)
·Blood sugar below 50 mg/dL or above 400 mg/dL (very low or very high sugar can mimic stroke and must be fixed first)
·Patient is on blood thinners or has a bleeding disorder (raises the risk of dangerous bleeding during treatment)

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Workup

·Non-contrast head CT
·CT angiography (CTA) of head and neck
·CT blood flow (perfusion) or MRI diffusion/blood flow imaging
·Serum glucose
·Complete blood count (CBC) with platelet count
·PT/INR and aPTT
·Electrocardiogram (ECG) and telemetry monitoring
·Troponin and BNP (if cardiac source suspected)

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Treatment

·IV alteplase (0.9 mg/kg, max 90 mg) or tenecteplase (0.25 mg/kg, single bolus) within 4.5 hours of last known well time
·Mechanical thrombectomy (catheter to pull out the clot) for large vessel blockage (occlusion), up to 24 hours from last known well in selected patients with favorable imaging
·Blood pressure control: keep < 185/110 mmHg before thrombolysis, < 180/105 mmHg for 24 hours after thrombolysis
·Aspirin 325 mg within 24–48 hours after stroke onset (but NOT in the first 24 hours after thrombolysis)
·High-intensity statin therapy (atorvastatin 80 mg or rosuvastatin 20 mg daily) started in hospital
·Anticoagulation (apixaban, rivaroxaban, dabigatran, or warfarin) for atrial fibrillation (an irregular, quivering heartbeat) or other cardioembolic source, started after brain imaging rules out bleeding-driven (hemorrhagic) transformation (typically 4–14 days post-stroke depending on size)
·Decompressive hemicraniectomy (surgical removal of part of the skull) for malignant MCA tissue death from blocked blood flow (infarction) with brain swelling in patients ≤ 60 years old, within 48 hours of symptom onset

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NCLEX trap

·In acute blood-starved (ischemic) stroke, the high blood pressure is the body's rescue attempt — the heart is pumping harder to force blood past the blocked pipe and feed the tissue that still has a chance. Dropping it fast starves that tissue at the edge (called the penumbra) and kills it. Current guidelines (AHA/ASA 2019) say keep blood pressure under 185/110 before thrombolysis, under 180/105 after — but do NOT use aggressive agents that crash it. Only lower it if it stays above 220/120 or the patient needs thrombolysis.
·The stroke window timer starts from last known well — the moment the brain was definitely normal. A patient found at 2 pm who was last seen normal at noon has a 2-hour window, not counting the time no one was watching. If you wake up with stroke symptoms, your last known well is when you went to bed. This is critical because thrombolysis (clot-busting medicine) is only safe within 4.5 hours of last known well (AHA/ASA 2019).
·You must see the brain image first. Giving thrombolysis to a patient with a bleeding-driven (hemorrhagic) stroke (bleeding stroke) is like pouring gasoline on a fire — you will make the bleeding worse and kill the patient. The image decides whether you treat clot or bleed. CT head without contrast is the first test, done within 20 minutes of arrival (AHA/ASA target). Only after it shows no bleed can you give thrombolysis.
·The 4.5-hour window is for IV medicine (alteplase or tenecteplase). Mechanical thrombectomy — using a tiny tube with a wire basket to pull out the clot — can work up to 24 hours from last known well if the patient has the right penumbra signature on imaging (showing tissue that is sick but still alive) and a big vessel clot (in the internal carotid, middle cerebral, or basilar artery). AHA/ASA 2018 and 2019 guidelines say thrombectomy up to 6 hours for most, and up to 24 hours in selected patients based on CT blood flow (perfusion) or MRI diffusion-blood flow mismatch.
·A stroke affecting the brainstem or the facial and throat muscles can paralyze swallowing without the patient knowing it. Talking does not mean swallowing is safe. Test swallow with water and a formal swallow evaluation (by a speech therapist or bedside swallow screen) first. Aspiration — food or liquid going into the lungs instead of the stomach — is a crash point that leads to pneumonia and death. Keep the patient nothing by mouth (NPO) until cleared by swallow screen (AHA/ASA 2019).

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