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neuro.ischaemic-stroke.v1PRODUCTION
neuro.ischaemic-stroke.v1

Acute Ischaemic Stroke

neurologyacuteadult
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Canonical 12-phase frame with authored status for this dossier.

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Acute focal deficit suggesting ischaemia — exclude hemorrhage, mimic, post-ictal (AHA/ASA 2019)

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Patient inputs (14)

Age affects EVT eligibility and bleeding risk (AHA/ASA 2019; DESTINY II, Jüttler NEJM 2014 — age <60 for hemicraniectomy)

Hypoglycaemia mimics stroke; hyperglycaemia worsens outcome (AHA/ASA 2019 Class I)

eGFR for contrast (CTA/CTP) and DOAC dose adjustment (AHA/ASA 2019)

Rule out hemorrhage before thrombolysis; ASPECTS scoring (AHA/ASA 2019 Class I)

LVO identification for EVT triage (AHA/ASA 2019 Class I)

NIHSS gates thrombolysis and EVT eligibility (≥6 for EVT; AHA/ASA 2019 Class I)

LKW determines tPA/TNK window ≤4.5 h (ECASS III, Hacke NEJM 2008) and EVT window ≤6 h or 6–24 h with mismatch (DAWN, Nogueira NEJM 2018; DEFUSE 3, Albers NEJM 2018)

SBP <185/110 pre-tPA; <180/105 × 24 h post-tPA (AHA/ASA 2019 Class I); <220/120 if no thrombolysis

INR >1.7 contraindicates thrombolysis per AHA/ASA 2019 exclusion criteria

Platelets <100k contraindicates thrombolysis per AHA/ASA 2019 exclusion criteria

DOAC last dose; need anti-Xa or DTI levels; affects tPA eligibility (AHA/ASA 2019)

Major surgery <14 d / GI/GU bleed <21 d are tPA contraindications (AHA/ASA 2019)

Mismatch selection for 6–24 h window (DAWN, Nogueira NEJM 2018; DEFUSE 3, Albers NEJM 2018)

AF as cardioembolic source → anticoagulation timing decision (2024 ESC AF guidelines)

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Severity triggers (13)

13 need judgement
  • informationallife_threateningbasilar_occlusion
    Basilar artery occlusion — any NIHSS (ATTENTION 2022; BAOCHE 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghemorrhagic_transformation_post_tpa
    New severe headache, HTN, N/V, or NIHSS decline ≥4 within 24 h post-tPA (AHA/ASA 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmalignant_mca_pattern
    NIHSS ≥15, infarct >50% MCA territory on imaging, age <60, decline within 48 h (DESTINY II, Jüttler NEJM 2014)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelvo_within_24h
    LVO on CTA + within 24 h LKW + ASPECTS ≥6 OR imaging mismatch (AHA/ASA 2019 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenihss_deterioration_ge_4
    NIHSS increase ≥4 points within 24 h regardless of pre-existing therapy (AHA/ASA 2019 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretoast_laa_phenotype
    TOAST class: large-artery atherosclerosis — carotid stenosis ≥50% ipsilateral on CTA/MRA/duplex OR intracranial atherosclerosis on vessel wall MRI
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretoast_ce_phenotype
    TOAST class: cardioembolic — AF on telemetry/ECG; LV thrombus on TTE; mechanical valve; large embolic-pattern infarct (cortical or multi-territory)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretoast_ode_phenotype
    TOAST class: other-determined etiology — vessel-wall MRI dissection sign; antiphospholipid antibodies positive; hypercoag panel positive (protein C/S, antithrombin, factor V Leiden); CNS vasculitis on DSA
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepre_tpa_bp_above_ceiling
    SBP >185 OR DBP >110 with otherwise tPA-eligible patient (AHA/ASA 2019 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepost_tpa_bp_above_ceiling
    SBP >180 OR DBP >105 within 24 h post-tPA (AHA/ASA 2019 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedysphagia_aspiration_risk
    Failed bedside swallow screen (3-oz water test, GUSS, or formal SLP evaluation) prior to any PO including oral medications (AHA/ASA 2019 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetoast_svo_phenotype
    TOAST class: small-vessel occlusion (lacunar) — infarct <1.5 cm on DWI in perforator territory; classic lacunar syndrome (pure motor, pure sensory, ataxic-hemiparesis, sensorimotor, dysarthria-clumsy-hand)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetoast_ude_phenotype
    TOAST class: undetermined etiology (cryptogenic / ESUS) — all large-artery + cardioembolic + small-vessel workup negative
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

Acute reperfusion (IV thrombolysis ± EVT) + BP control + early antiplatelet (AHA/ASA 2019)
axis: acute_reperfusion_and_bpstep 1 - Step 1 — IV thrombolysis ≤4.5 h (NINDS 1995; ECASS III, Hacke NEJM 2008)
Selected step "Step 1 — IV thrombolysis ≤4.5 h (NINDS 1995; ECASS III, Hacke NEJM 2008)" — LKW ≤4.5 h, no hemorrhage on CT, no exclusion per AHA/ASA 2019 (recent surgery <14 d, GI/GU bleed <21 d, INR >1.7, platelets <100k, BP cannot be controlled <185/110, recent stroke <3 mo)
  • alteplase
    first line
    tissue_plasminogen_activator
    0.9 mg/kg IV (max 90 mg); 10% as bolus over 1 min, remaining 90% as infusion over 60 min • IV • single course (max: 90 mg total)
    triggers: LKW_<=4.5h, no_hemorrhage, no_contraindication
    NINDS / ECASS-III — thrombolysis ≤4.5h reduces disability
    rxcui 8410
  • tenecteplase
    first line
    tissue_plasminogen_activator
    0.25 mg/kg IV single bolus over 5 sec (max 25 mg) • IV • single bolus (max: 25 mg total)
    triggers: LKW_<=4.5h, AcT_eligible
    AcT (Lancet 2022) — TNK 0.25 mg/kg non-inferior to alteplase; preferred per 2026 AHA/ASA
    rxcui 259280

outpatient playbook — drug actions (5)

  1. 1. atorvastatin
    80 mg PO daily • PO • once daily
    trigger: Atherosclerotic stroke; LDL ≥55
    2026 ACC/AHA Lipid — high-intensity statin LDL <55 mg/dL post-stroke (AHA/ASA 2021 Class I)
  2. 2. apixaban OR rivaroxaban
    Apixaban 5 mg PO BID (2.5 mg if 2 of: age ≥80 / weight ≤60 kg / Cr ≥1.5); rivaroxaban 20 mg PO daily with food (15 mg if CrCl 15–50) • PO • BID / daily
    trigger: AF detected; sustained per ESC AF
    2024 ESC AF — DOAC preferred; ARISTOTLE / ROCKET-AF anchor
  3. 3. aspirin
    81 mg PO daily • PO • once daily
    trigger: Non-cardioembolic stroke; no DAPT indication
    AHA/ASA 2021 — chronic antiplatelet for non-cardioembolic ischemic stroke
  4. 4. ACEI/ARB + thiazide
    Lisinopril 10–40 mg PO daily; chlorthalidone 12.5–25 mg PO daily; titrate to BP <130/80 • PO • daily
    trigger: BP ≥130/80
    2025 AHA/ACC HTN; PROGRESS trial perindopril-indapamide reduced recurrent stroke
  5. 5. varenicline OR nicotine replacement OR bupropion
    Varenicline 0.5 mg PO daily × 3 d → 0.5 BID × 4 d → 1 mg BID × 11 wk • PO / patch / lozenge • per agent
    trigger: Active tobacco use
    AHA/ASA 2021 Class I — smoking cessation pharmacotherapy for stroke survivors

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Sudden focal neurological deficit (FAST/BEFAST; AHA/ASA 2019); Aphasia / dysarthria of sudden onset (AHA/ASA 2019); Hemiparesis / facial droop (AHA/ASA 2019).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Ischaemic Stroke** (neuro.ischaemic-stroke.v1).
Phenotype framing: TOAST classification (Adams Stroke 1993): large-artery atherothrombotic / cardioembolic / lacunar / cryptogenic / other
Scope: Acute focal deficit suggesting ischaemia — exclude hemorrhage, mimic, post-ictal (AHA/ASA 2019)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute reperfusion (IV thrombolysis ± EVT) + BP control + early antiplatelet (AHA/ASA 2019)** — step "Step 1 — IV thrombolysis ≤4.5 h (NINDS 1995; ECASS III, Hacke NEJM 2008)".
1. alteplase 0.9 mg/kg IV (max 90 mg); 10% as bolus over 1 min, remaining 90% as infusion over 60 min IV single course (tissue_plasminogen_activator, first line) — NINDS / ECASS-III — thrombolysis ≤4.5h reduces disability
2. tenecteplase 0.25 mg/kg IV single bolus over 5 sec (max 25 mg) IV single bolus (tissue_plasminogen_activator, first line) — AcT (Lancet 2022) — TNK 0.25 mg/kg non-inferior to alteplase; preferred per 2026 AHA/ASA

Setting playbook (outpatient) — Stroke-clinic follow-up at 90 d + 12 mo: TOAST-driven secondary prevention reconciliation, BP <130/80, LDL <55, DOAC adherence, mRS outcome capture, post-stroke depression / cognitive screen, OSA + driving + vocational evaluation (AHA/ASA 2021)
3. atorvastatin 80 mg PO daily PO once daily — Atherosclerotic stroke; LDL ≥55 (2026 ACC/AHA Lipid — high-intensity statin LDL <55 mg/dL post-stroke (AHA/ASA 2021 Class I))
4. apixaban OR rivaroxaban Apixaban 5 mg PO BID (2.5 mg if 2 of: age ≥80 / weight ≤60 kg / Cr ≥1.5); rivaroxaban 20 mg PO daily with food (15 mg if CrCl 15–50) PO BID / daily — AF detected; sustained per ESC AF (2024 ESC AF — DOAC preferred; ARISTOTLE / ROCKET-AF anchor)
5. aspirin 81 mg PO daily PO once daily — Non-cardioembolic stroke; no DAPT indication (AHA/ASA 2021 — chronic antiplatelet for non-cardioembolic ischemic stroke)
6. ACEI/ARB + thiazide Lisinopril 10–40 mg PO daily; chlorthalidone 12.5–25 mg PO daily; titrate to BP <130/80 PO daily — BP ≥130/80 (2025 AHA/ACC HTN; PROGRESS trial perindopril-indapamide reduced recurrent stroke)
7. varenicline OR nicotine replacement OR bupropion Varenicline 0.5 mg PO daily × 3 d → 0.5 BID × 4 d → 1 mg BID × 11 wk PO / patch / lozenge per agent — Active tobacco use (AHA/ASA 2021 Class I — smoking cessation pharmacotherapy for stroke survivors)

Non-pharmacologic actions:
- AHA "Get With The Guidelines" outcome measure documentation — mRS, smoking cessation, statin compliance, BP at target, antithrombotic on board, AF screen completed (AHA/ASA 2021)
- Recurrent-stroke counselling — symptom recognition, when to call 911, do NOT delay even if symptoms transient
- Advance directives + power-of-attorney discussion (AHA/ASA 2021)
- Pulmonary rehab referral if comorbid COPD (GOLD 2026)
- Diabetes self-management education if applicable (ADA 2026)
- Sleep study (PSG or home test) if STOP-BANG ≥3 (AHA/ASA 2021)
- Polysomnography-directed CPAP titration if OSA confirmed (AHA/ASA 2021)
- Mediterranean diet counselling (PREDIMED trial)
- Aerobic exercise prescription 150 min/wk moderate intensity (AHA/ASA 2021 Class I)

AVOID / contraindication checks:
- TPA_contraindications_INR_platelets_recent_surgery (AHA/ASA 2019)
- TPA_BP_<185/110_required_pre_thrombolysis (AHA/ASA 2019 Class I)
- DAPT_only_minor_stroke_or_high_risk_TIA (POINT 2018; CHANCE 2013)
- Antiplatelet_after_tPA_wait_24h_with_repeat_CT (AHA/ASA 2019 Class I)
- Glucose_correction_before_code_stroke (AHA/ASA 2019)

Monitoring

Regimen monitoring:
- NIHSS q15 min during tPA infusion (AHA/ASA 2019)
- NIHSS q1 h × 24 h post-tPA (AHA/ASA 2019)
- BP q15 min × 2 h then q30 min × 6 h then q1 h (AHA/ASA 2019)
- Repeat CT at 24 h post-tPA before antiplatelet (AHA/ASA 2019 Class I)
- Continuous telemetry for AF detection (AHA/ASA 2019)
- Glucose q4 h target 140–180 mg/dL (AHA/ASA 2019)

Setting (outpatient) monitoring:
- Clinic visit at 7–14 d post-discharge for medication reconciliation (AHA/ASA 2021)
- Stroke clinic at 90 d (mRS, secondary prevention bundle audit) and 12 mo (long-term outcome)
- BP home log + clinic check q3 mo until at goal then q6 mo (2025 AHA/ACC HTN)
- Lipid panel at 4–6 wk after statin start; then q6–12 mo (2026 ACC/AHA Lipid)
- HbA1c q3 mo if diabetic until controlled, then q6 mo (ADA 2026)
- Renal function q6 mo on DOAC; q3 mo if CrCl 30–50 (2024 ESC AF)
- INR weekly until stable then q4 wk if on warfarin (ACCP 2018)
- PHQ-9 + MoCA at 90 d, 6 mo, 12 mo (AHA/ASA 2021)

Follow-up plan: Secondary prevention: high-intensity statin LDL <55 (2026 ACC/AHA Lipid), BP <130/80 (2025 AHA/ACC HTN), DAPT/anticoag per source, dysphagia/SLP, rehab, AF screen
- Close-out criterion: secondary-prevention bundle prescribed + outpatient stroke clinic scheduled

Monitoring phase: Neuro checks q15 min × 2 h → q30 min × 6 h → q1 h × 16 h; BP per AHA/ASA 2019 protocol; continuous telemetry for AF

Disposition

Current setting: outpatient — Stroke-clinic follow-up at 90 d + 12 mo: TOAST-driven secondary prevention reconciliation, BP <130/80, LDL <55, DOAC adherence, mRS outcome capture, post-stroke depression / cognitive screen, OSA + driving + vocational evaluation (AHA/ASA 2021)

Disposition criteria:
- Continue indefinite secondary-prevention regimen — no de-escalation of antiplatelet/anticoagulant unless explicit risk-benefit shift (AHA/ASA 2021)
- Transition from rehab to community-based exercise programs at 6–12 mo per functional status (AHA/ASA 2021)

Escalation triggers (move to higher acuity):
- Any new TIA-spectrum or stroke-like event → ED (AHA/ASA 2021)
- BP persistently >140/90 despite 3-drug regimen → resistant HTN workup (cardio.htn.resistant.v1; 2025 AHA/ACC HTN)
- PHQ-9 ≥15 OR suicidal ideation → urgent psych referral (AHA/ASA 2021)
- MoCA <26 OR cognitive decline noted by family → neurocognitive workup; consider donepezil per AHA/ASA 2021
- Statin intolerance → ezetimibe + PCSK9i if LDL >55 (2026 ACC/AHA Lipid)
- DOAC bleeding event → temporary hold, reversal if life-threatening (idarucizumab / andexanet), reassess net benefit

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Basilar artery occlusion — any NIHSS (ATTENTION 2022; BAOCHE 2022)
- [LIFE_THREATENING] New severe headache, HTN, N/V, or NIHSS decline ≥4 within 24 h post-tPA (AHA/ASA 2019)
- [LIFE_THREATENING] NIHSS ≥15, infarct >50% MCA territory on imaging, age <60, decline within 48 h (DESTINY II, Jüttler NEJM 2014)

Citations

- 2026 AHA/ASA Guideline for the Early Management of Patients With Acute Ischemic Stroke (Stroke 2026; DOI 10.1161/STR.0000000000000513) + 2024 AHA/ASA Primary Prevention + 2024 ESC AF + 2025 AHA/ACC HTN + 2026 ACC/AHA Dyslipidemia [PMID:7477192](https://pubmed.ncbi.nlm.nih.gov/7477192/)
- Cited evidence (PMID 18815396) [PMID:18815396](https://pubmed.ncbi.nlm.nih.gov/18815396/)
- Cited evidence (PMID 35779553) [PMID:35779553](https://pubmed.ncbi.nlm.nih.gov/35779553/)
- Cited evidence (PMID 25517348) [PMID:25517348](https://pubmed.ncbi.nlm.nih.gov/25517348/)
- Cited evidence (PMID 25671798) [PMID:25671798](https://pubmed.ncbi.nlm.nih.gov/25671798/)

Last reconciled with current guidelines: 2026-05-18.
References
  • 2026 AHA/ASA Guideline for the Early Management of Patients With Acute Ischemic Stroke (Stroke 2026; DOI 10.1161/STR.0000000000000513) + 2024 AHA/ASA Primary Prevention + 2024 ESC AF + 2025 AHA/ACC HTN + 2026 ACC/AHA Dyslipidemia — PMID:7477192
  • Cited evidence (PMID 18815396) — PMID:18815396
  • Cited evidence (PMID 35779553) — PMID:35779553
  • Cited evidence (PMID 25517348) — PMID:25517348
  • Cited evidence (PMID 25671798) — PMID:25671798