17.1 Acute Ischemic Stroke & Intracranial Hemorrhage

ABFM Family Medicine Certification Study Guide Exam

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1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

2.1 Practice Management, Billing, Coding & Documentation 2.2 Quality Improvement, Patient Safety & Diagnostic Stewardship 2.3 Interprofessional Team-Based Care & Care Coordination

3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

3.1 Medical Ethics, Informed Consent & Surrogate Decision-Making 3.2 Biostatistics, Clinical Epidemiology & Diagnostic Test Interpretation 3.3 Social Determinants of Health, Health Equity & Cultural Humility 3.4 Physician Wellness, Burnout Prevention & Professionalism

4 Chapter 4: Lifestyle Counseling & Behavior Change

4.1 Alcohol Use Screening & Brief Intervention 4.2 Illicit Drug & Cannabis Counseling 4.3 Tobacco & Vaping Cessation Counseling

5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

5.1 Dietary Counseling for Obesity & Chronic Disease Prevention 5.2 Exercise Prescription & Physical Activity Counseling 5.3 Genetic Risk Assessment & Family History Counseling

6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

9.1 Cardiovascular Disease & Hypertension Screening 9.2 Type 2 Diabetes Screening & Prediabetes Risk Stratification 9.3 Abdominal Aortic Aneurysm & Osteoporosis Screening

10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage

Key Takeaways Explain This Topic AI

Intravenous thrombolysis with alteplase (0.9 mg/kg, max 90 mg; 10% bolus over 1 min, remainder over 60 min) or tenecteplase (0.25 mg/kg single bolus, max 25 mg) must be initiated within 4.5 hours of last known well after ruling out acute hemorrhage on non-contrast CT and confirming absence of absolute contraindications (prior ICH, head trauma/stroke within 3 months, platelets <100,000/µL, INR >1.7, DOAC within 48 hours, refractory BP >185/110 mm Hg, blood glucose <50 mg/dL).

Endovascular thrombectomy (EVT) is standard of care for large vessel occlusions (LVO: internal carotid artery or MCA M1 segment) within 6 hours of symptom onset, and up to 24 hours based on DAWN and DEFUSE 3 trial clinical-core or perfusion-core mismatch criteria.

In acute ischemic stroke NOT treated with thrombolysis or EVT, permissive hypertension is maintained up to 220/120 mm Hg to preserve collateral penumbral perfusion; if receiving thrombolysis or EVT, blood pressure must be reduced to <185/110 mm Hg prior to infusion and maintained <180/105 mm Hg for the subsequent 24 hours using titratable IV labetalol or nicardipine.

In acute spontaneous intracerebral hemorrhage (ICH), immediate systolic blood pressure lowering to a target of 130 to 140 mm Hg (INTERACT-2 and ATACH-2) within hours prevents hematoma expansion without causing renal ischemia; coagulopathy reversal must occur emergently (4F-PCC + IV Vitamin K for warfarin; idarucizumab for dabigatran; andexanet alfa or 4F-PCC for factor Xa inhibitors).

Elevated intracranial pressure (ICP) secondary to large hemispheric infarction or hematoma requires head of bed elevation to 30 degrees, midline neck positioning, osmotic therapy (hypertonic 3% saline or 20% mannitol), and brief hyperventilation (PaCO2 30–35 mm Hg) strictly as a temporizing rescue bridge to emergent decompressive hemicraniectomy or hematoma evacuation.

Last updated: September 2026

Emergency Triage & The "Time Is Brain" Paradigm

Acute stroke is a hyperacute medical emergency wherein approximately 1.9 million neurons, 14 billion synapses, and 12 km (7.5 miles) of myelinated axonal fibers are destroyed each minute that a large vessel occlusion remains untreated. Rapid emergency triage and streamlined multidisciplinary protocols are critical to salvage the ischemic penumbra—the rim of structurally intact, hypoperfused neural tissue surrounding the irreversibly infarcted core.

Prehospital Stroke Screening Tools

Prehospital identification by emergency medical services (EMS) activates hospital "Code Stroke" teams prior to patient arrival, dramatically reducing door-to-needle (DTN) and door-to-puncture times.

FAST Screen : F ace drooping, A rm weakness, S peech difficulty, T ime to call emergency services. Widely utilized, highly sensitive (~85%) for anterior circulation hemispheric strokes.

BE-FAST Screen : Adds B alance (acute ataxia, gait unsteadiness) and E yes (sudden loss of vision, diplopia, conjugate gaze deviation). Increases sensitivity for posterior circulation strokes (vertebrobasilar territory) from 85% to >95%.

Cincinnati Prehospital Stroke Scale (CPSS) : Evaluates 3 findings: facial droop (have patient smile/show teeth), motor arm drift (eyes closed, arms extended 10 seconds), and abnormal speech ("The sky is blue in Cincinnati"). If any 1 of the 3 parameters is abnormal, the probability of an acute ischemic stroke is 72% ; if all 3 are present, the probability exceeds 85% .

American Heart Association / American Stroke Association (AHA/ASA) Target Metrics

• Process Step AHA/ASA Quality Metric Goal
• Door-to-Physician Initial Evaluation ≤ 10 minutes
• Door-to-Stroke Team Activation ≤ 15 minutes
• Door-to-Non-Contrast Head CT / MRI Initiation ≤ 20 minutes
• Door-to-CT / Neuroimaging Interpretation ≤ 45 minutes

Door-to-Needle (IV Thrombolytic Administration) ≤ 60 minutes (ideal target ≤ 45 minutes; top tier ≤ 30 minutes)

Door-to-Groin Puncture (Endovascular Thrombectomy) ≤ 90 minutes (for direct arrivals) / ≤ 60 minutes (for transfer patients)

Immediate Bedside Resuscitation & Triage Rules

Airway, Breathing, Circulation (ABCs) : Support ventilation and oxygenation; administer supplemental oxygen only if oxygen saturation (SpO2) falls <94%. Hyperoxia induces reactive oxygen species and cerebral vasoconstriction.

Point-of-Care Capillary Blood Glucose (STAT) : The single mandatory lab test that must not delay thrombolysis . Hypoglycemia (<50 mg/dL) is the most frequent stroke mimic and can produce focal hemiplegia, aphasia, and altered sensorium. If hypoglycemia is present, treat immediately with 25 to 50 mL of 50% dextrose (D50W) IV and reassess neurological status. Hyperglycemia (>180 mg/dL) also worsens ischemic neuronal injury and must be treated with subcutaneous or IV regular insulin.

Peripheral Venous Access & STAT Laboratory Panels : Place two large-bore peripheral IV lines (avoid central lines or arterial punctures that preclude thrombolytic administration). Draw CBC with platelets, PT/INR, aPTT, troponin, and type and screen. Crucial Rule : In patients without a known history of thrombocytopenia, hepatic failure, or anticoagulant therapy, intravenous thrombolysis must NOT be delayed while awaiting laboratory results .

The National Institutes of Health Stroke Scale (NIHSS)

The NIHSS is a validated, 11-domain quantitative neurological scoring tool ranging from 0 to 42 points that objectively measures acute neurological deficit severity, monitors clinical trajectory, predicts vascular occlusion sites, and stratifies outcomes.

NIHSS Structural Components (11 Domains)

1a. Level of Consciousness (LOC) : 0 = Alert; 1 = Not alert, arousable by minor stimulation; 2 = Not alert, requires repeated/painful stimulation; 3 = Comatose/unresponsive. 1b. LOC Questions : Ask patient their current month and age (0 = Both correct; 1 = One correct; 2 = Neither correct). 1c. LOC Commands : Ask patient to open/close eyes and grip/release non-paretic hand (0 = Both correct; 1 = One correct; 2 = Neither correct).

Best Gaze : Horizontal eye movements (0 = Normal; 1 = Partial gaze palsy; 2 = Forced deviation or total gaze paresis).

Visual Fields : Confrontation testing in all 4 quadrants (0 = No visual loss; 1 = Partial hemianopia; 2 = Complete hemianopia; 3 = Bilateral hemianopia / cortical blindness).

Facial Palsy : Symmetry of smile, eyebrow elevation, and eye closure (0 = Normal; 1 = Minor asymmetry; 2 = Partial lower facial palsy; 3 = Complete unilateral facial paralysis).

Motor Arm (Left & Right tested separately) : Limb held at 90° seated or 45° supine for 10 seconds (0 = No drift; 1 = Drift before 10s; 2 = Some effort against gravity; 3 = No effort against gravity; 4 = No movement; UN = Amputation/joint fusion).

Motor Leg (Left & Right tested separately) : Limb held at 30° supine for 5 seconds (0 = No drift; 1 = Drift before 5s; 2 = Some effort against gravity; 3 = No effort against gravity; 4 = No movement).

Limb Ataxia : Finger-to-nose and heel-to-shin testing out of proportion to weakness (0 = Absent; 1 = Present in one limb; 2 = Present in two limbs).

Sensory : Pinprick response compared bilaterally (0 = Normal; 1 = Mild-to-moderate partial sensory loss; 2 = Severe/total sensory loss).

Best Language : Describe the Cookie Theft picture, name common objects, and read standard sentences (0 = No aphasia; 1 = Mild-to-moderate aphasia; 2 = Severe receptive/expressive aphasia; 3 = Mute / global aphasia).

Dysarthria : Articulation of words like "mama," "tip-top," "fifty-fifty," "baseball player" (0 = Normal; 1 = Mild-to-moderate slurring; 2 = Severe dysarthria / anarthria; UN = Intubated).

Extinction & Inattention (Neglect) : Double simultaneous visual and cutaneous sensory stimulation (0 = No neglect; 1 = Visual, tactile, auditory, or spatial hemi-inattention; 2 = Profound hemi-inattention in >1 modality).

Clinical Interpretation & Large Vessel Occlusion (LVO) Correlation

Score 0 : Normal neurological examination.

Score 1–4 : Minor / mild stroke (often eligible for thrombolysis if deficits are functionally disabling, e.g., isolated hemianopia, aphasia, or distal hand weakness).

Score 5–15 : Moderate stroke.

Score 16–20 : Moderate-to-severe stroke.

Score 21–42 : Severe stroke (approaches >70% risk of severe disability or in-hospital mortality).

High-Yield Exam Pearl : An NIHSS score ≥ 6 (or presence of cortical signs: gaze deviation, aphasia, hemineglect) strongly predicts an anterior circulation Large Vessel Occlusion (LVO) involving the internal carotid artery terminus or proximal middle cerebral artery (MCA M1 segment), mandating emergent vascular imaging for mechanical thrombectomy.

Emergent Neuroimaging: Non-Contrast CT, CTA, and Perfusion Mismatch

Emergency neuroimaging must be initiated within 20 minutes of hospital arrival. The primary objective is to differentiate acute ischemic stroke from intracranial hemorrhage and identify large vessel occlusions amenable to catheter-directed intervention.

1. Non-Contrast Head CT (NCCT)

Primary Role : The immediate gold standard to definitively exclude acute intracranial hemorrhage (ICH) , which presents as bright, hyperdense parenchymal, intraventricular, or subarachnoid blood.

Early Ischemic Changes (EIC) : In acute infarction, cytotoxic edema causes water influx into neurons and glial cells, decreasing tissue X-ray attenuation (hypoattenuation):

Hyperdense Middle Cerebral Artery Sign : Increased radiodensity within the M1 segment of the MCA, reflecting acute intraluminal thromboembolism.

Insular Ribbon Sign : Loss of gray-white matter differentiation in the insular cortex.

Obscuration of the Lentiform Nucleus : Blurring of the putamen and globus pallidus borders.

Cortical Sulcal Effacement : Localized effacement of cortical sulci secondary to gyral swelling.

Alberta Stroke Program Early CT Score (ASPECTS) :

A 10-point topographic quantitative scoring system of the MCA territory on axial NCCT at two standardized levels (ganglionic and supraganglionic).

The territory is partitioned into 10 regions: Caudate, Lentiform, Internal capsule, Insular cortex, and 6 cortical MCA territories (M1 to M6).

1 point is subtracted for each region demonstrating early ischemic hypoattenuation. A normal CT scores 10 . An ASPECTS < 6 correlates with a large, established ischemic core (>70 mL), predicting poor functional recovery and a high risk of hemorrhagic transformation.

2. CT Angiography (CTA) of Head and Neck

Performed immediately following NCCT (single-session multiphase CTA) from the aortic arch to the vertex of the skull.

Rapidly identifies high-grade arterial stenosis, cervical dissection (intimal flap, flame-shaped occlusion), and anterior or posterior circulation Large Vessel Occlusions (carotid siphon/terminus, MCA M1/M2 bifurcation, basilar artery, vertebral arteries).

3. Advanced Perfusion Imaging (CT Perfusion & MRI DWI-PWI)

Utilizes automated deconvolution software (e.g., RAPID) to quantitatively distinguish irreversibly dead brain tissue from salvageable penumbra:

Ischemic Core : Irreversibly infarcted tissue defined on CT Perfusion as cerebral blood flow ( CBF < 30% of normal contralateral tissue) or on MRI as high-signal restricted diffusion on Diffusion-Weighted Imaging (DWI) with corresponding low Apparent Diffusion Coefficient (ADC) .

Ischemic Penumbra : Hypoperfused tissue at risk of infarction defined as time-to-maximum ( Tmax > 6 seconds ).

Mismatch Volume & Ratio : Mismatch Volume = Volume(Tmax > 6s) - Volume(CBF < 30%). A mismatch ratio ≥ 1.8 and absolute mismatch volume ≥ 15 mL identifies patients who benefit dramatically from reperfusion therapy up to 24 hours after onset.

Intravenous Thrombolytic Therapy (Alteplase & Tenecteplase)

Intravenous thrombolysis degrades fibrin within occlusive thrombi by converting plasminogen to active plasmin, re-establishing microvascular and macrovascular perfusion.

Pharmacological Regimens

Alteplase (Recombinant Tissue Plasminogen Activator, rtPA) :

Dosing : 0.9 mg/kg IV (maximum cumulative dose 90 mg ).

Administration Protocol : Infuse 10% of the total calculated dose as an intravenous bolus over 1 minute ; infuse the remaining 90% continuously over 60 minutes via an infusion pump.

Tenecteplase (TNK-tPA) :

Dosing : 0.25 mg/kg IV (maximum dose 25 mg ), administered as a single intravenous bolus over 5 to 10 seconds .

Guideline Status : Now recognized as an evidence-based alternative to alteplase. Tenecteplase possesses higher fibrin specificity, an 80-fold resistance to plasminogen activator inhibitor-1 (PAI-1), and a longer elimination half-life. Single-bolus administration significantly accelerates workflow and facilitates inter-facility transfers for mechanical thrombectomy.

Therapeutic Eligibility Windows

Standard Window (<3 Hours) : Established by the landmark 1995 NINDS trial; demonstrated a >30% relative increase in patients achieving minimal or no disability (modified Rankin Scale 0–1) at 3 months.

Extended Window (3 to 4.5 Hours) : Established by the European ECASS-III trial; expands eligibility to select patients presenting between 3 and 4.5 hours from last known well.

"Wake-Up Stroke" & Unknown Onset Time : In patients who awaken with stroke symptoms or have unwitnessed onset >4.5 hours from last known well, intravenous thrombolysis is indicated if an MRI demonstrates a DWI-FLAIR mismatch (positive restricted diffusion on DWI representing acute ischemia, with absence of parenchymal hyperintensity on FLAIR , proving that the stroke is <4.5 hours old; WAKE-UP trial).

Inclusion & Exclusion Criteria for Intravenous Thrombolysis INTRAVENOUS THROMBOLYSIS ELIGIBILITY SCREENING

• ┌────────────────────────────────────────────────────────────────────────┐
• │ CLINICAL INCLUSION CRITERIA: │
• │ 1. Diagnosis of acute ischemic stroke causing measurable neurologic │
• │ deficit (NIHSS ≥4 or disabling deficit) │
• │ 2. Time from Last Known Well <4.5 hours (or MRI DWI-FLAIR mismatch) │
• │ 3. Age ≥18 years │
• └───────────────────────────────────┬────────────────────────────────────┘
• │
• ▼
• ┌────────────────────────────────────────────────────────────────────────┐
• │ ABSOLUTE CONTRAINDICATIONS (DO NOT ADMINISTER): │
• │ • Non-contrast CT demonstrates acute intracranial hemorrhage or │
• │ frank hypodensity involving >1/3 of the MCA territory │
• │ • Previous history of ANY intracranial hemorrhage (ICH, SAH, AVM) │
• │ • Severe head trauma or acute ischemic stroke within preceding 3 MONTHS│
• │ • Intracranial or intraspinal surgery within preceding 3 MONTHS │
• │ • Active internal bleeding (e.g., acute GI ulcer hemorrhage, hematuria)│
• │ • Suspected aortic arch dissection or infective endocarditis │
• │ • Platelet count <100,000/µL │
• │ • Coagulopathy: INR >1.7, PT >15 seconds, or aPTT >40 seconds │
• │ • Therapeutic Direct Oral Anticoagulant (DOAC) ingestion within 48h │
• │ • Blood pressure >185 mm Hg systolic or >110 mm Hg diastolic refractory│
• │ to emergency intravenous antihypertensive therapy │
• │ • Blood glucose <50 mg/dL (unless deficit persists post-correction) │
• └───────────────────────────────────┬────────────────────────────────────┘
• │
• ▼
• ┌────────────────────────────────────────────────────────────────────────┐
• │ RELATIVE CONTRAINDICATIONS & EXTENDED 3–4.5h CAUTIONS (ECASS-III): │
• │ • Age >80 years (guidelines permit treatment with shared decision) │
• │ • Severe baseline stroke severity (NIHSS >25) │
• │ • Concomitant history of prior ischemic stroke AND diabetes mellitus │
• │ • Current treatment with oral anticoagulants (regardless of INR) │
• │ • Major surgery or serious non-head trauma within preceding 14 days │
• │ • Gastrointestinal or urinary tract hemorrhage within prior 21 days │
• │ • Arterial puncture at non-compressible site within prior 7 days │
• └────────────────────────────────────────────────────────────────────────┘
• Post-Thrombolysis Management & Critical Complications

Monitoring : Frequent vital signs and neurological assessments (every 15 minutes for 2 hours, every 30 minutes for 6 hours, then hourly for 16 hours).

Blood Pressure Target : Maintain BP <180/105 mm Hg continuously for at least 24 hours post-thrombolysis.

Antithrombotic Hold : Withhold all antiplatelet agents (aspirin, clopidogrel) and parenteral/oral anticoagulants for 24 hours . Obtain a follow-up non-contrast head CT or MRI at 24 hours to rule out asymptomatic or symptomatic hemorrhage before initiating antiplatelet therapy.

Emergency Management of Complications :

Symptomatic Intracranial Hemorrhage (sICH) : Occurs in ~6% of alteplase patients (NINDS). Suspect immediately if acute headache, acute hypertension, nausea/vomiting, or sudden drop in NIHSS score (≥ 2 points) occurs.

Protocol : Stop thrombolytic infusion immediately! Obtain STAT non-contrast head CT. Draw STAT type and screen, PT/INR, aPTT, fibrinogen, and platelets.

Medical Reversal : Administer Cryoprecipitate 10 units IV (infuse over 10–20 minutes; replenishes fibrinogen; target fibrinogen >150 mg/dL; repeat if necessary). Administer Tranexamic Acid (TXA) 1000 mg IV over 10 minutes (or aminocaproic acid 4–5 g IV). Consult neurosurgery emergently.

Orolingual Angioedema : Occurs in 1–5% of patients due to bradykinin accumulation, especially those taking concurrent ACE inhibitors . Characterized by unilateral or bilateral tongue, lip, and oropharyngeal swelling.

Protocol : Stop thrombolysis infusion immediately. Administer IV Methylprednisolone 125 mg , IV Diphenhydramine 50 mg , and IV Famotidine 20 mg . For rapidly progressive airway compromise, administer subcutaneous/IM epinephrine 0.3 mg (0.3 mL of 1:1000) and prepare for emergent awake fiberoptic endotracheal intubation or surgical cricothyroidotomy.

Endovascular Thrombectomy (EVT) for Large Vessel Occlusion

Mechanical thrombectomy utilizes intra-arterial microcatheters, stent retrievers (e.g., Solitaire, Trevo), and direct contact aspiration catheters to mechanically extract large occlusive emboli from proximal intracranial arteries.

Standard 0 to 6 Hour Window (HERMES Meta-Analysis)

Class I, Level A indication for patients meeting all of the following criteria:

• Age ≥ 18 years;
• Pre-stroke modified Rankin Scale (mRS) score 0 or 1 (functionally independent);
• Causative occlusion of the Internal Carotid Artery (ICA) or proximal Middle Cerebral Artery M1 segment ;
• Baseline NIHSS score ≥ 6 ;
• Initial ASPECTS score ≥ 6 on NCCT;

Treatment can be initiated (groin puncture) within 6 hours of symptom onset . Bridging Paradigm : Eligible patients presenting <4.5 hours should receive intravenous thrombolysis immediately; do not wait to observe the clinical effect of IV thrombolysis before transferring to the catheterization laboratory .

Extended 6 to 24 Hour Window (DAWN & DEFUSE 3 Trials)

Patients presenting between 6 and 24 hours from last known well (including wake-up strokes and unwitnessed onsets) who have an anterior circulation LVO qualify for EVT based on automated CT perfusion or diffusion MRI tissue mismatch criteria :

DAWN Trial Criteria (Up to 24 Hours) : Based on clinical-core mismatch :

Group A: Age ≥ 80 years, NIHSS ≥ 10, and ischemic core volume <21 mL.

Group B: Age <80 years, NIHSS ≥ 10, and ischemic core volume <31 mL.

Group C: Age <80 years, NIHSS ≥ 20, and ischemic core volume 31 to 51 mL.

Result : Number needed to treat (NNT) of 2.8 to achieve functional independence (mRS 0–2) at 90 days.

DEFUSE 3 Trial Criteria (Up to 16 Hours) : Based on perfusion-core mismatch :

• Ischemic core volume <70 mL;
• Mismatch ratio (penumbra volume / core volume) ≥ 1.8;

Absolute penumbral volume ≥ 15 mL.

Result : Significant reduction in 90-day mortality and functional disability (NNT = 2.0 for improved functional score).

Hemodynamic & Blood Pressure Management in Acute Ischemic Stroke

Cerebral autoregulation is profoundly impaired in ischemic brain tissue. The cerebral perfusion pressure (CPP = MAP - ICP) within the ischemic penumbra depends linearly on systemic mean arterial pressure (MAP). Precipitous blood pressure drops collapse collateral leptomeningeal flow and convert salvageable penumbra into necrotic core.

Blood Pressure Algorithms in Acute Ischemic Stroke BLOOD PRESSURE TARGETS IN ACUTE ISCHEMIC STROKE

• ┌────────────────────────────────────────────────────────────────────────┐
• │ PATIENTS NOT RECEIVING REPERFUSION (NO THROMBOLYSIS OR EVT): │
• │ • PERMISSIVE HYPERTENSION: Allow BP up to 220/120 mm Hg │
• │ • Do NOT treat unless SBP >220 mm Hg or DBP >120 mm Hg │
• │ • If BP >220/120 mm Hg: Lower BP by a cautious 15% over the first 24h │
• │ • EXCEPTION: Treat BP immediately if concurrent acute aortic │
• │ dissection, acute MI, pulmonary edema, or hypertensive encephalopathy│
• └────────────────────────────────────────────────────────────────────────┘

• ┌────────────────────────────────────────────────────────────────────────┐
• │ PATIENTS CANDIDATES FOR IV THROMBOLYSIS OR EVT: │
• │ • BEFORE THROMBOLYSIS: BP must be lowered to <185/110 mm Hg │
• │ • DURING & FOR 24 HOURS POST-THROMBOLYSIS: Maintain BP <180/105 mm Hg │
• │ • POST-SUCCESSFUL EVT (TICI 2b/3): Target SBP <140–160 mm Hg to prevent│
• │ reperfusion injury and hyperperfusion syndrome │
• └────────────────────────────────────────────────────────────────────────┘
• Preferred Intravenous Antihypertensive Pharmacotherapy

IV Labetalol :

Dose: 10 to 20 mg IV bolus over 1 to 2 minutes ; may repeat once or double the dose every 10 minutes (e.g., 20 mg, 40 mg, 80 mg) up to a cumulative maximum dose of 300 mg .

Mechanism: Combined competitive antagonist at alpha-1 and beta-adrenergic receptors (beta-to-alpha ratio 7:1 IV), lowering systemic vascular resistance without inducing reflex tachycardia.

IV Nicardipine :

Dose: Continuous intravenous infusion initiated at 5 mg/hour ; titrate upward by 2.5 mg/hour every 5 to 15 minutes until desired target is reached (maximum infusion rate 15 mg/hour ). Once blood pressure stabilizes, down-titrate to 3 mg/hour.

Mechanism: Dihydropyridine L-type calcium channel blocker; selective arterial vasodilator with rapid titration kinetics.

IV Clevidipine :

Dose: Continuous infusion initiated at 1 to 2 mg/hour ; double the dose every 90 seconds until blood pressure approaches target; titrate by smaller increments every 5 to 10 minutes (maximum dose 32 mg/hour ).

Mechanism: Third-generation ultra-short-acting dihydropyridine CCB rapidly metabolized by blood and tissue esterases (t1/2 ≈ 1 minute), eliminating dependency on renal or hepatic clearance.

STRICTLY CONTRAINDICATED : Sublingual or immediate-release oral nifedipine (causes erratic, uncontrollable precipitous hypotension, reflex sympathetic stimulation, and watershed cerebral infarction).

Spontaneous Intracerebral Hemorrhage (ICH)

Spontaneous non-traumatic intracerebral hemorrhage accounts for 10% to 15% of all strokes and carries a 30-day mortality approaching 40% to 50% . Up to 35% of hematomas expand significantly within the first 6 hours , making hyperacute hemostatic and blood pressure stabilization vital.

Etiological Subtypes & Anatomical Distribution

Hypertensive Microangiopathy (Arteriolosclerosis, ~60–70% of ICH) :

Longstanding systemic hypertension produces fibrinoid necrosis, lipohyalinosis, and microaneurysmal dilatation ( Charcot-Bouchard microaneurysms ) of small, deep penetrating parenchymal arteries (50–150 µm diameter).

Predilection Sites : Putamen and basal ganglia (50%), thalamus (15%), pons (10%), and deep cerebellar hemispheres (10%).

Cerebral Amyloid Angiopathy (CAA, ~20–30% of ICH) :

Progressive deposition of beta-amyloid peptide (Aβ40) within the media and adventitia of small-to-medium cortical and leptomeningeal arteries, weakening vessel architecture.

Predilection Sites : Exclusively lobar cortical and subcortical regions (frontal, parietal, temporal, occipital lobes) in elderly individuals (>65 years); strictly spares the deep basal ganglia and brainstem.

High propensity for recurrent lobar hemorrhages and cognitive decline.

Secondary Etiologies : Arteriovenous malformations (AVMs), cavernous hemangiomas, dural arteriovenous fistulas, ruptured saccular aneurysms, hemorrhagic conversion of ischemic stroke, cerebral venous sinus thrombosis, intracranial neoplasms (choriocarcinoma, melanoma, renal cell carcinoma, glioblastoma), and sympathomimetic illicit drug toxicity (cocaine, methamphetamine).

Non-Contrast CT Findings in ICH

Hyperdense Intraparenchymal Hematoma : Bright white parenchymal attenuation (60–80 Hounsfield Units) with distinct margins.

Perihematomal Vasogenic Edema : Surrounding dark, hypodense rim reflecting secondary inflammatory capillary breakdown.

Mass Effect : Compression of adjacent brain parenchyma, effacement of the ipsilateral lateral ventricle, and midline shift of the septum pellucidum across the falx cerebri.

Intraventricular Extension (IVH) : Blood breaking into the ventricular system; dramatically increases mortality and risks acute obstructive hydrocephalus requiring an external ventricular drain (EVD).

The CT Angiography "Spot Sign" : Multifocal foci of contrast enhancement within the hematoma during CTA; represents active extravasation and strongly predicts rapid hematoma expansion.

Acute Blood Pressure Control in Intracerebral Hemorrhage

Elevated systolic blood pressure drives active ongoing bleeding and hematoma expansion. However, excessive reduction risks renal injury and cerebral hypoperfusion.

Guideline Blood Pressure Target : Rapidly lower systolic blood pressure to a target of 130 to 140 mm Hg within 1 to 2 hours of arrival.

Landmark Clinical Trial Evidence :

INTERACT-2 Trial : Early intensive blood pressure lowering (target SBP <140 mm Hg within 1 hour) compared to standard lowering (<180 mm Hg) was safe, reduced hematoma growth, and showed significant improvements in functional recovery (better mRS scores).

ATACH-2 Trial : Compared target SBP 110–139 mm Hg against 140–179 mm Hg using IV nicardipine. Demonstrated that targeting SBP <120 mm Hg provided no additional clinical benefit and caused a significantly higher incidence of acute kidney injury and cardiac events.

Clinical Bottom Line : Target SBP 130–140 mm Hg with continuous IV nicardipine or clevidipine; strictly avoid dropping SBP <120 mm Hg .

Emergency Anticoagulant Reversal Protocols in ICH

Patients taking therapeutic anticoagulants who suffer an ICH experience catastrophic hematoma enlargement. Coagulopathy reversal must be initiated immediately upon CT confirmation of hemorrhage.

Anticoagulant Class First-Line Emergency Reversal Agent Dosing & Administration Protocol Mechanism of Action / Clinical Pearls

Warfarin (Vitamin K Antagonist) 4-Factor Prothrombin Complex Concentrate (4F-PCC) (Kcentra) ; PLUS ; Intravenous Vitamin K1 Weight- & INR-based 4F-PCC :; • INR 2.0–<4.0: 25 units/kg (max 2500 U); • INR 4.0–6.0: 35 units/kg (max 3500 U); • INR >6.0: 50 units/kg (max 5000 U); (or fixed dose 1500–2000 U IV) ; PLUS IV Vitamin K1 10 mg in 50 mL saline over 30 min 4F-PCC contains concentrated factors II, VII, IX, X, and proteins C and S. Restores factor levels within 10–15 min. Vitamin K provides sustained factor synthesis (PCC factor half-life is ~6h). FFP is inferior (requires ABO matching, hours to thaw/infuse, risks volume overload [TACO]).

Dabigatran (Direct Thrombin Inhibitor) Idarucizumab (Praxbind) 5 grams IV , administered as two consecutive 2.5-gram IV infusions over 5 to 10 minutes each Humanized monoclonal Fab fragment with 350-fold higher affinity for dabigatran than thrombin. Neutralizes >99% of free and bound dabigatran within minutes. If unavailable, administer 4F-PCC 50 units/kg.

Oral Factor Xa Inhibitors (Apixaban, Rivaroxaban, Edoxaban) Andexanet alfa (Andexxa) ; OR ; 4-Factor PCC (4F-PCC) Andexanet alfa :; • Low dose : 400 mg IV bolus @ 30 mg/min, then 4 mg/min for 120 min (for apixaban/rivaroxaban ≤ 10 mg taken >8h ago); • High dose : 800 mg IV bolus @ 30 mg/min, then 8 mg/min for 120 min (for rivaroxaban >10 mg or taken <8h ago); Alternative (4F-PCC) : 50 units/kg IV (max 5000 U) Andexanet alfa is a recombinant modified human factor Xa decoy protein that sequesters Xa inhibitors. When unavailable or cost-prohibitive, guidelines strongly endorse 4F-PCC 50 units/kg IV as a highly effective, accessible alternative.

Unfractionated Heparin (UFH) Protamine Sulfate 1 mg IV per 100 units of UFH administered in preceding 2 hours (max single dose 50 mg; infuse over 10 min) Positively charged alkaline protein that complexes with negatively charged heparin. Rapid infusion causes severe hypotension and anaphylactoid shock.

Low-Molecular-Weight Heparin (LMWH) Protamine Sulfate 1 mg IV per 1 mg of enoxaparin given within 8 hours (0.5 mg per 1 mg enoxaparin if given 8–12 hours) Reverses ~60% of anti-Xa activity of LMWH.

• Management of Increased Intracranial Pressure (ICP) & Impending Herniation
• Pathophysiology & Monro-Kellie Doctrine

The cranial vault is an inelastic, rigid box with a fixed total internal volume composed of three compartments: brain parenchyma (80%), cerebrospinal fluid (10%), and intravascular blood (10%). An acute pathological mass (e.g., intraparenchymal hematoma or massive hemispheric ischemic edema) initially triggers compensatory spatial displacement of CSF into the lumbar spinal subarachnoid space and venous blood into the jugular system. Once compensatory mechanisms are exhausted, intracranial pressure (ICP) rises exponentially .

Normal ICP: 5 to 15 mm Hg .

Pathological Intracranial Hypertension: ICP > 20 mm Hg .

Cerebral Perfusion Pressure (CPP): CPP = MAP - ICP. Target CPP is 60 to 70 mm Hg . If ICP surges or MAP plunges, CPP drops below 50 mm Hg, inducing global secondary cerebral ischemia.

Cushing's Triad (ominous sign of impending brainstem herniation): Severe hypertension with widened pulse pressure, bradycardia, and irregular respirations (Cheyne-Stokes or ataxic) .

Stepwise Medical Management of Increased ICP STEPWISE ICP MANAGEMENT CASCADE

• ┌────────────────────────────────────────────────────────────────────────┐
• │ TIER 1: GENERAL PHYSIOLOGICAL & POSITIONING MEASURES │
• │ • Elevate Head of Bed to 30 DEGREES with neck in neutral midline │
• │ position (unimpeded jugular venous return) │
• │ • Loosen endotracheal tube ties and cervical collars │
• │ • Aggressive Normothermia: Scheduled acetaminophen; target <37.5°C │
• │ • Analgesia & Mild Sedation: IV fentanyl/propofol to prevent shivering,│
• │ coughing, and posturing spikes in ICP │
• │ • Avoid Hypotonic IV fluids (use ONLY isotonic 0.9% saline) │
• └───────────────────────────────────┬────────────────────────────────────┘
• │
• ▼
• ┌────────────────────────────────────────────────────────────────────────┐
• │ TIER 2: OSMOTIC THERAPY (TARGET SERUM OSMOLALITY <320 mOsm/kg) │
• │ • HYPERTONIC 3% SALINE: 250 mL IV bolus over 15–30 min, or continuous │
• │ infusion targeting serum Na+ 145–155 mEq/L (expands intravascular │
• │ volume; preferred in hemodynamically unstable patients) │
• │ • 20% MANNITOL: 0.5 to 1.0 g/kg IV bolus over 20 min (causes osmotic │
• │ diuresis; monitor volume status; contraindicated in hypotension) │
• └───────────────────────────────────┬────────────────────────────────────┘
• │
• ▼
• ┌────────────────────────────────────────────────────────────────────────┐
• │ TIER 3: TEMPORIZING EMERGENCY RESCUE INTERVENTIONS │
• │ • BRIEF CONTROLLED HYPERVENTILATION: Target PaCO2 30–35 mm Hg │
• │ - Induces cerebral vasoconstriction; decreases cerebral blood volume │
• │ - STRICT RULE: Use ONLY as a temporary rescue bridge (15–30 min) │
• │ while mobilizing neurosurgery; prolonged hyperventilation causes │
• │ severe rebound cerebral ischemia │
• │ • High-Dose Barbiturates (Pentobarbital coma) for refractory ICP │
• └───────────────────────────────────┬────────────────────────────────────┘
• │
• ▼
• ┌────────────────────────────────────────────────────────────────────────┐
• │ SURGICAL DECOMPRESSION (DEFINITIVE RESCUE): │
• │ • Cerebellar Hemorrhage (≥3 cm or brainstem compression/hydrocephalus): │
• │ EMERGENT Suboccipital Craniectomy & Hematoma Evacuation │
• │ • Malignant MCA Infarction (age ≤60, large volume): Decompressive │
• │ Hemicraniectomy within 48 hours (reduces mortality from 70% to 20%) │
• └────────────────────────────────────────────────────────────────────────┘

STRICT CONTRAINDICATION TO CORTICOSTEROIDS : High-dose dexamethasone or methylprednisolone is effective for vasogenic edema surrounding brain neoplasms and CNS infections, but is strictly contraindicated in acute ischemic stroke and intracerebral hemorrhage . Randomized trials demonstrate no reduction in ICP, no improvement in outcomes, and significantly higher rates of lethal infections, hyperglycemia, and mortality.

Loading diagram... Emergency Diagnostic & Therapeutic Algorithm for Acute Stroke and Intracranial Hemorrhage