ACLS | Stroke Extended

1. Core Epidemiology & Stroke Types

• Ischemic Stroke (87%): Resulting from arterial occlusion; prime candidate for rapid reperfusion therapies (IV alteplase and endovascular therapy)[1].
• Hemorrhagic Stroke (13%): Caused by cerebral vessel rupture; IV fibrinolytics and anticoagulants are strictly contraindicated[1].
• Ischemic Penumbra: Dysfunctional but viable brain tissue surrounding the central infarct core that reperfusion strategies aim to preserve[2][3].

2. Prehospital Assessment & The 8 D's of Stroke Care

• The 8 D's: Detection, Dispatch, Delivery, Door, Data, Decision, Drug/Device, and Disposition[4].
• Prehospital Screening (CPSS): Evaluates Facial Droop, Arm Drift, and Abnormal Speech. A single abnormal finding yields a 72% stroke probability[5].
• Critical EMS Actions: Assess ABCs, check point-of-care blood glucose (treat hypoglycemia <60 mg/dL)[5][6], establish Last Known Normal (LKN) time[5][7], provide hospital prenotification, and bypass ED to CT suite[7][8].

3. In-Hospital Time Targets (NINDS & Target: Stroke)

• Door-to-Assessment: Immediate general assessment within 10 minutes; neurologic exam within 20 minutes[9].
• Door-to-CT/MRI: Noncontrast CT acquired within 20 minutes; expert scan interpretation within 45 minutes[9].
• Door-to-Needle (Alteplase): Administer within 60 minutes of arrival (Target: Stroke III goal: ≥85% within 60 min)[7][9].
• Door-to-Device (EVT): First pass within 90 minutes (direct arrival) or 60 minutes (transfers)[7][9].
• Treatment Windows:
  • IV Alteplase: Within 3 hours (extended to 4.5 hours for select eligible patients)[1].
  • Endovascular Therapy (EVT): Up to 24 hours from onset for confirmed Large Vessel Occlusion (LVO)[9][11].

4. Blood Pressure Thresholds & Pharmacotherapy

• Pre-Alteplase BP Goal: Lower blood pressure to ≤185/110 mmHg before initiating IV alteplase[12].
• Post-Reperfusion Goal: Maintain BP ≤180/105 mmHg for at least 24 hours post-alteplase[12].
• First-Line IV Antihypertensives: Labetalol (10–20 mg IV), Nicardipine (5–15 mg/h IV), or Clevidipine (1–2 mg/h IV)[7][12].

5. Key Contraindications & Stroke System Levels

• Absolute Exclusions: Intracranial Hemorrhage (ICH) on NCCT/MRI[2][13], severe head trauma or ischemic stroke within 3 months[13], prior history of ICH[13], active GI bleed within 21 days[13], or coagulopathy (platelets <100k, INR >1.7, aPTT >40s)[14].
• Stroke Facility Levels: Acute Stroke Ready (ASRH), Primary (PSC), Thrombectomy-Capable (TSC), and Comprehensive Stroke Centers (CSC)[15][16].