Evidence-based guideline for recognition, evaluation, thrombolysis, thrombectomy, and management of ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage in the emergency department.
A comprehensive, evidence-based clinical guideline for the emergency department recognition, evaluation, and management of acute stroke — including ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. This resource synthesizes recommendations from the major international stroke and cardiovascular professional societies, emergency medicine expert panels, neurointerventional working groups, and European stroke organizations into a single integrated reference for emergency physicians, neurologists, neurointerventionalists, intensivists, and advanced practice providers who manage patients presenting with acute cerebrovascular emergencies.1 2 3 4 5 6 7
Stroke is the fifth leading cause of death and a leading cause of serious long-term disability in the United States, with approximately 795,000 people experiencing a new or recurrent stroke each year. Globally, stroke is the second leading cause of death and third leading cause of disability. The foundational principle of acute stroke management — “time is brain” — reflects the estimated loss of 1.9 million neurons per minute during a large vessel occlusion. The paradigm has shifted from a purely time-based approach to one that integrates tissue-based imaging (perfusion mismatch) to identify patients who may benefit from reperfusion therapy even in extended time windows. The cornerstones of acute stroke care — rapid recognition, emergent neuroimaging, intravenous thrombolysis, endovascular thrombectomy, blood pressure management, and neuroprotective strategies — are supported by robust randomized controlled trial evidence and form the basis of modern stroke systems of care.
Contents:
| Part | Title | Coverage |
|---|---|---|
| Part 1 | Prehospital Recognition, ED Evaluation & Neuroimaging | Stroke types and pathophysiology; prehospital stroke scales (CPSS, LAMS, RACE, FAST-ED, VAN); ED evaluation; complete NIHSS scoring table (all 15 items); focused history; laboratory evaluation; neuroimaging (NCCT, CTA, CTP, MRI/DWI); ASPECTS scoring with complete regional anatomy |
| Part 2 | Intravenous Thrombolysis | Alteplase dosing and administration; 0-3 hour and 3-4.5 hour inclusion/exclusion criteria (complete tables); tenecteplase emerging evidence (AcT, TASTE, ATTEST-2); blood pressure management before and after thrombolysis; orolingual angioedema recognition and management; hemorrhagic transformation |
| Part 3 | Endovascular Thrombectomy & Blood Pressure Management | EVT indications and patient selection; landmark trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT); extended window therapy (DAWN, DEFUSE-3); door-to-groin targets; anesthesia considerations (GA vs conscious sedation); comprehensive BP management across all stroke types; antihypertensive agent dosing tables |
| Part 4 | Intracerebral Hemorrhage | ICH pathophysiology and etiology; ICH Score (complete table); hematoma expansion prediction; acute blood pressure management (INTERACT2, ATACH-2); anticoagulant reversal (warfarin, DOACs, heparin — complete protocols); surgical intervention criteria (STICH, STICH II, MISTIE III, ENRICH); ICP management; prognostication |
| Part 5 | Subarachnoid Hemorrhage, TIA & Special Populations | SAH presentation and diagnosis; Hunt & Hess scale; WFNS grade; Fisher/modified Fisher CT grading; aneurysm securing (coiling vs clipping); vasospasm prevention (nimodipine); delayed cerebral ischemia; TIA evaluation (ABCD2 score, dual antiplatelet — CHANCE, POINT); stroke mimics; posterior circulation stroke; wake-up stroke; stroke in pregnancy; pediatric stroke |
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SAH presentation, Hunt & Hess scale, WFNS grade, Fisher CT grading, aneurysm management, vasospasm prevention, DCI, TIA evaluation (ABCD2, dual antiplatelet), stroke mimics, posterior circulation, wake-up stroke, pregnancy, and pediatric stroke.
ICH pathophysiology, ICH Score, hematoma expansion, blood pressure management (INTERACT2, ATACH-2), anticoagulant reversal protocols, surgical intervention criteria (STICH, MISTIE III, ENRICH), and ICP management.
EVT indications, landmark trials, extended window therapy (DAWN, DEFUSE-3), anesthesia considerations, and comprehensive blood pressure management with antihypertensive dosing tables.
Alteplase and tenecteplase dosing, complete inclusion/exclusion criteria for 0-3h and 3-4.5h windows, blood pressure management peri-thrombolysis, orolingual angioedema, and hemorrhagic transformation.
Stroke types, prehospital stroke scales (CPSS, LAMS, RACE, FAST-ED), complete NIHSS scoring, focused history, laboratory evaluation, and neuroimaging (NCCT, CTA, CTP, MRI/DWI, ASPECTS).