On CCS, a stroke patient is your race against time. You have minutes to recognize the symptom onset, order the right imaging, determine if the patient is tPA-eligible, and execute the treatment protocol. The difference between a patient who recovers neurologically and one who suffers permanent disability hangs on your ability to apply the "time-is-brain" principle: every hour of ischemia causes irreversible brain damage. This article is your complete clinical guide to recognizing stroke, calculating the NIH Stroke Scale, determining tPA candidacy, and managing both ischemic and hemorrhagic strokes on CCS.
Time-Is-Brain: The Fundamental Principle of Acute Stroke
The core concept driving acute stroke management is that neurons are dying every minute. For ischemic stroke, each minute of ischemia causes approximately 1.9 million neuron deaths. This translates to aggressive time-sensitive management.
Ischemic Stroke Therapeutic Windows
• 0-3 hours: IV thrombolysis (tPA) indicated if criteria met
• 3-4.5 hours: IV thrombolysis may be considered (if ≤80 years old, non-diabetic, no prior stroke)
• 0-24 hours: Mechanical thrombectomy (select patients with large vessel occlusion in anterior circulation)
Key Timelines to Know
• Last known well to CT: Target <25 minutes
• CT to decision to treat: <20 minutes
• Door-to-needle for tPA: Goal <60 minutes (ideally <30 minutes)
• Every 15 minutes delay in treatment increases poor outcome risk by 10%
Acute Ischemic Stroke: Recognition and Diagnosis
FAST Assessment (Face, Arm, Speech, Time)
This is your rapid screening tool on CCS. If any component positive, assume stroke until proven otherwise.
• Face: Ask patient to smile. Look for facial drooping or asymmetry.
• Arm: Have patient raise both arms. Look for drift (one arm drifting down).
• Speech: Have patient repeat a simple phrase ("The quick brown fox jumps over the lazy dog"). Listen for slurring, difficulty speaking, or inappropriate words.
• Time: If any abnormality, note time of onset. This is critical for treatment decisions.
NIH Stroke Scale (NIHSS): Quantifying Neurologic Deficit
The NIHSS is a standardized 15-item assessment that quantifies stroke severity. Score 0-42 (higher = more severe). On CCS, you'll document the NIHSS to support your stroke diagnosis and assess treatment response.
NIHSS Components (simplified for CCS):
1. Consciousness: Alert (0), drowsy but arousable (1), comatose/unresponsive (2)
2. Level of consciousness questions: Ability to answer "What month is it?" and "How old are you?" (0-2)
3. Level of consciousness commands: Ability to follow "Open and close your eyes" and "Make a fist" (0-2)
4. Gaze: Any abnormal gaze preference or gaze paralysis (0-2)
5. Visual fields: Test each field. Homonymous hemianopia = 1 or 2
6. Facial palsy: Any drooping observed (0-3)
7. Motor arm: Drift in each arm at 10 seconds (0-4 each arm)
8. Motor leg: Drift in each leg at 5 seconds (0-4 each leg)
9. Limb ataxia: Dysmetria in gross motor functions (0-2)
10. Sensory: Loss of sensation to pinprick (0-2)
11. Best language: Naming, repetition, comprehension (0-3)
12. Dysarthria: Slurring, difficulty speaking (0-2)
13. Extinction and inattention: Neglect or extinction to double-simultaneous stimulation (0-2)
Interpreting NIHSS on CCS:
• 0: No stroke
• 1-4: Minor stroke (good prognosis)
• 5-15: Moderate stroke (mixed prognosis)
• 16-20: Moderate-to-severe stroke (high morbidity risk)
• >20: Severe stroke (high mortality/morbidity risk)
> Study Tip: The StudyCCS question bank includes 15+ stroke cases where you must calculate NIHSS, identify the time of onset, and determine tPA eligibility. Real-time grading shows which findings you should document.
Imaging Decision: CT Head First
Stat non-contrast head CT is mandatory to differentiate ischemic from hemorrhagic stroke. This cannot wait for any other workup.
Ischemic stroke findings on CT:
• Early signs: Subtle hypodensity in gray matter (basal ganglia, insular cortex), loss of gray-white matter differentiation
• Often CT is normal in hyperacute ischemia (<6 hours)
• Alberta Stroke Program Early CT Score (ASPECTS): Grading scale (0-10) predicting outcomes. Higher score = better prognosis.
Hemorrhagic stroke findings on CT:
• Acute blood appears hyperdense (white)
• Location tells you the type: Basal ganglia/thalamus (hypertensive), lobar (amyloid), brainstem/pons (pontine), cerebellum (cerebellar)
Additional Imaging
CT angiography (CTA head/neck):
• Indications: Consider if thrombus characteristics matter for treatment decisions (mechanical thrombectomy, collateral assessment)
• Timing: Can be done urgently if ischemic stroke confirmed on CT
MRI brain:
• Better for detecting ischemia than CT (especially early ischemia <24 hours)
• More time-consuming than CT
• Use for chronic assessment or if diagnosis unclear after CT
IV Thrombolysis (tPA): Criteria, Dosing, and Management
tPA Candidacy: Inclusion Criteria
• Acute ischemic stroke (diagnosed by clinical assessment and imaging)
• Time window: 0-3 hours from onset (or 3-4.5 hours if meets criteria below)
◦ For 3-4.5 hour window: Age ≤80, no history of both diabetes and prior stroke, NIHSS ≤25, no oral anticoagulation
• No contraindications (see below)
• Can quantify neurologic deficit (use NIHSS)
tPA Contraindications (Absolute and Relative)
Absolute contraindications:
• Evidence of intracranial hemorrhage on CT
• Suspected subarachnoid hemorrhage (even if CT negative, consider LP)
• Recent major surgery, head trauma, or myocardial infarction within 3 months
• History of intracranial hemorrhage
• Severe uncontrolled hypertension (SBP >185 or DBP >110) before tPA, not responsive to treatment
• Recent stroke within 3 months
• Active internal bleeding
• Platelet count <100,000
• INR >1.7 (on warfarin) or PT >15 seconds
• Recent heparin therapy with elevated aPTT
• Blood glucose <50 or >400 mg/dL
Relative contraindications (use clinical judgment):
• Mild neurologic deficit
• Seizure at stroke onset (unless stroke suspected)
• Pregnancy
• Recent myocardial infarction (3-12 months)
• Uncontrolled diabetes
tPA Dosing and Administration
• Dose: 0.9 mg/kg (max 90 mg)
• First 10% as bolus IV over 1 minute
• Remaining 90% as infusion over 60 minutes
• Example: 70 kg patient = 63 mg total
◦ 6.3 mg IV bolus over 1 minute
◦ 56.7 mg IV infusion over 60 minutes
Order on CCS:
"Acute ischemic stroke protocol. tPA 0.9 mg/kg IV: [X] mg IV bolus over 1 minute, then [Y] mg IV infusion over 60 minutes. Continuous cardiac monitoring. Check glucose. Strict BP control (<185/110). Neuro checks q15 min during and q30 min after infusion."
tPA Management and Monitoring
• Strict blood pressure control: Keep SBP <185 and DBP <110 during and after tPA (prevents reperfusion hemorrhage)
◦ If hypertensive: IV labetalol 10-20 mg over 1-2 minutes, repeat q10 min to max 300 mg. Or IV nicardipine 5 mg/hr, titrate up
• Neurologic assessment: Every 15 minutes during infusion, q30 minutes for 2-8 hours, then q1-2h
• Watch for: Deterioration in mental status, new focal deficit, severe headache (signs of hemorrhagic transformation)
• Anticoagulation: Hold anticoagulants and antiplatelets for 24 hours post-tPA (risk of bleeding)
• ICU admission: Monitor q4h for 24 hours post-tPA; many facilities admit to ICU or stroke unit
> Practice Alert: tPA management is one of the highest-yield CCS topics. The StudyCCS question bank includes cases where you must identify tPA contraindications, calculate dosing, and manage BP during and after thrombolysis. Practice builds the speed you need on exam day.
Mechanical Thrombectomy: Indications and When to Consult
Mechanical Thrombectomy Candidacy
• Large vessel occlusion (LVO) in anterior circulation (ICA, M1, M2 MCA)
• Within 24 hours of symptom onset (extended window if meets criteria)
• Selected patients: NIHSS >6, no large infarct core on imaging, ASPECTS >5
• No major contraindications
Decision Tree
1. Patient meets tPA criteria? Give tPA (even if also thrombectomy candidate)
2. Confirm large vessel occlusion: CTA head showing thrombus in ICA/M1/M2
3. Is patient a thrombectomy candidate? Call neurology or neurointerventional radiology STAT
4. Proceed to OR/interventional suite immediately if appropriate
Order on CCS:
"Neurology consult STAT. Assess for mechanical thrombectomy candidacy. CTA head to identify vessel occlusion. Contact neurointerventional radiology if appropriate for emergent thrombectomy."
Acute Hemorrhagic Stroke: Recognition and Management
Hemorrhagic Stroke Types and Causes
Intracerebral Hemorrhage (ICH): Bleeding into brain parenchyma
• Hypertensive: Basal ganglia, thalamus, pons, cerebellum (deep structures; 50-60% of ICH)
• Amyloid angiopathy: Lobar hemorrhage in older patients
• Anticoagulation: Warfarin (INR elevated), direct oral anticoagulants, heparin
• Thrombolytic: tPA, streptokinase
• Hemorrhagic transformation: Of ischemic stroke
• AVM/aneurysm: Mass effect, rebleeding risk
Subarachnoid Hemorrhage (SAH): Bleeding into subarachnoid space
• Most common causes: Ruptured aneurysm (80%), trauma, AVM, coagulopathy
• Presentation: Worst headache of life, neck stiffness, photophobia, focal neurologic deficit
• Diagnosis: CT head (if negative but high suspicion, LP with cell count and xanthochromia)
Hemorrhagic Stroke Management
Immediate Orders:
• Stat non-contrast head CT (confirms hemorrhage)
• Two large-bore IVs
• Continuous cardiac monitoring
• Neuro checks q15-30 min
• NPO (risk of airway compromise, possible intubation)
• Foley catheter
• Labs: CBC, CMP, coagulation studies, blood type and cross
• Type and cross blood (may need transfusion)
Blood Pressure Management (Critical in ICH):
• Goal: Lower BP to <140/90 mmHg (aggressive BP lowering improves outcome in ICH)
• First-line agents:
◦ IV labetalol 10-20 mg over 1-2 minutes, repeat q10 min (max 300 mg)
◦ IV nicardipine 5 mg/hr, titrate up by 5 mg/hr q5 min to goal (max 15 mg/hr)
◦ Hydralazine 10-20 mg IV q20-30 min (slower, use if labetalol/nicardipine unavailable)
• Avoid: Hypotonic fluids (risk of cerebral edema); excessive aggressive lowering (>30% in first hour) may worsen outcomes
• Target: Achieve goal BP within 1 hour of presentation
Coagulopathy Reversal:
• Warfarin: Give vitamin K 10 mg IV (slow, takes 12-24 hours) + fresh frozen plasma or prothrombin complex concentrate
• Dabigatran: Idarucizumab 5 grams IV (specific reversal agent)
• Rivaroxaban/Apixaban: Apixaban has specific reversal (apixaban), rivaroxaban has andexanet alfa; FFP/PCC as alternatives
• Heparin: Protamine sulfate (1 mg per 100 units heparin, max 50 mg)
Hemostatic Therapy:
• Transfuse platelets if <100,000 or actively bleeding
• Consider recombinant factor VIIa (off-label, controversial in some centers)
Edema Management:
• Head of bed elevated 30 degrees
• Osmotic therapy if mass effect or edema worsening:
◦ Hypertonic saline 3% (250 mL bolus) or
◦ Mannitol 1 g/kg IV over 15-30 minutes (less common now, risk of rebound edema)
• Avoid hypoxia, hypercapnia, hyperthermia (worsen edema)
Seizure Prophylaxis:
• Consider if lobar hemorrhage or cortical involvement
• Phenytoin or levetiracetam as short-term prophylaxis (not long-term monotherapy)
• Antiepileptic not indicated for basal ganglia/thalamic/infratentorial hemorrhage
Neurosurgery Consult:
• Indications: Large hemorrhage with mass effect, intraventricular extension, cerebellar hemorrhage, aneurysmal SAH, expanding hematoma
• Procedures: Hematoma evacuation, ventriculostomy (for hydrocephalus), coil or clipping (for aneurysm)
ICU Admission:
• All hemorrhagic strokes should be admitted to ICU (risk of deterioration, rebleeding, increased intracranial pressure)
• Monitoring: Neuro checks q1-2h x 24h, then q4h; repeat head CT if deterioration; continuous cardiopulmonary monitoring
> Study Tip: Hemorrhagic stroke management on CCS often hinges on knowing when to lower BP aggressively, when to reverse anticoagulation, and when to call neurosurgery. The StudyCCS question bank includes 10+ hemorrhagic stroke cases with real-time grading.
Post-Stroke Care and Secondary Prevention
Acute Phase Monitoring (First 24-48 Hours)
• Neuro deterioration: Can signal cerebral edema, hemorrhagic transformation, rebleeding, seizure, or complications
• DVT prophylaxis: Sequential compression devices; SC heparin if no contraindication
• Nutrition: Swallow evaluation before oral intake (aspiration risk)
• Stress ulcer prophylaxis: PPI or H2 blocker if hospitalized
• Temperature: Avoid fever (associated with worse outcomes); acetaminophen or cooling blanket if needed
Secondary Prevention (At Discharge and Beyond)
• Antiplatelet therapy: Aspirin 75-325 mg daily (unless contraindicated by hemorrhagic stroke or comorbidity)
• Statin: Atorvastatin 80 mg daily (regardless of LDL; reduces recurrent stroke)
• Antihypertensive: Continue/escalate BP medications to target <140/90 (discuss optimal target with neurology)
• Smoking cessation: Critical counseling
• Diabetes control: Tight glycemic control reduces recurrent stroke
• Lifestyle: Physical therapy, occupational therapy, speech therapy as needed
Disposition
• Ischemic stroke with good recovery: May discharge to home, rehabilitation facility, or acute rehab depending on functional status
• Hemorrhagic stroke: Usually requires longer hospitalization; many need acute/subacute rehabilitation
• Neurology follow-up: Arrange within 1-2 weeks
• Stroke risk factor modification: Cardiology if cardiac source of embolism; carotid imaging if large vessel disease suspected
Don't-Miss Diagnoses in Stroke
• Hemorrhagic transformation: Ischemic stroke converted to hemorrhagic (especially 24-72 hours post-tPA). Look for sudden neurologic deterioration, new headache, elevated BP.
• Expanded infarct: Deterioration despite tPA or mechanical thrombectomy from collateral failure or reocclusion. Repeat imaging indicated.
• Posterior circulation stroke: Vertigo, ataxia, visual field defect, facial numbness, dysarthria (brainstem signs). Often missed initially.
• Stroke mimic: Seizure, migraine, Todd's paralysis, Bell's palsy, functional disorder can mimic stroke. MRI helps differentiate.
• Cerebral venous sinus thrombosis: Young patient, recent surgery/hypercoagulable state, headache + focal deficit. CT venography needed.
• Subarachnoid hemorrhage: Worst headache of life + meningismus + focal deficit. CT followed by LP if CT negative.
Complete Order Set: Acute Stroke Management
Ischemic Stroke (tPA Candidate):
• Stat non-contrast head CT
• Two large-bore IVs; continuous cardiac monitoring
• Labs: CBC, CMP, coagulation studies, glucose, troponin, blood type and cross
• ECG (assess for atrial fibrillation, ACS)
• CTA head if time permits and mechanical thrombectomy being considered
• tPA dosing: [calculate 0.9 mg/kg]: [X] mg IV bolus over 1 minute, [Y] mg infusion over 60 minutes
• Strict BP control: Target SBP <185, DBP <110. Use IV labetalol or IV nicardipine
• Neuro checks q15 min during infusion, q30 min x 2 hours, then q1-2h
• Hold anticoagulants and antiplatelets x 24 hours
• ICU/stroke unit admission
• Neurology consult
Hemorrhagic Stroke:
• Stat non-contrast head CT (confirms ICH)
• Two large-bore IVs; continuous cardiac monitoring
• Labs: CBC, CMP, coagulation studies, glucose, troponin, blood type and cross
• Aggressive BP control: Target SBP <140. IV labetalol or IV nicardipine
• Reverse anticoagulation if on warfarin: Vitamin K + FFP/prothrombin complex concentrate
• Osmotic therapy if mass effect: 3% hypertonic saline 250 mL or mannitol 1 g/kg
• Seizure prophylaxis if lobar hemorrhage: Levetiracetam or phenytoin
• Head of bed 30 degrees; avoid hypoxia, hypercapnia, hyperthermia
• Neurosurgery consult
• ICU admission with neuro monitoring q1-2h x 24h
• DVT prophylaxis: SCD, consider SC heparin
2-Minute Screen: Acute Stroke Case Recognition
You see a case stem with acute neurologic symptoms. Fast assessment:
Red flags for acute stroke:
• Acute onset focal neurologic deficit (facial droop, arm drift, speech difficulty)
• Time: "Patient found down," "Symptom onset 2 hours ago," "Last known well 1 hour ago"
• Imaging mention: "CT shows hypodensity" (ischemia) or "CT shows hyperdensity" (hemorrhage)
Your 2-minute action:
1. Determine time of symptom onset. This drives all treatment decisions.
2. Order stat non-contrast head CT. Differentiate ischemic from hemorrhagic ASAP.
3. Calculate NIHSS using clinical findings (facial droop, arm drift, speech, etc.).
4. Check contraindications: BP control, glucose, coagulation status, recent surgery.
5. If ischemic + within 3 hours + no contraindications: Initiate tPA protocol.
6. If hemorrhagic: Aggressive BP control, reverse anticoagulation, neurosurgery consult.
7. Call neurology STAT. They'll assess for thrombectomy if appropriate.
Ready to Practice?
The StudyCCS question bank includes 25+ acute stroke cases with real-time scoring. Cases cover ischemic stroke with tPA decision-making, hemorrhagic stroke with BP management, and stroke mimics. Each case times your door-to-needle decisions and shows you exactly where you earn and lose points. Practice a case today and build the speed and precision you need on exam day.
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