Initial Assessment:

* Obtain Vitals and blood glucose level* Time of onset (important for tPA/TNK vs thrombectomy)* Neurologic and Cardiac Examination / NIHSS* do not delay head CT to complete NIHSS, can always finish after CT* Assess contraindications for tPA

Workup:

* Labs: CBC, CMP, Troponin, Coags, EtOH, bedside accucheck* CXR and UA (infections can cause recrudescence of prior cva)* ECG looking specifically for AFib* Stat Imaging: CT Head noncontrast, followed by CTA Head/Neck and/or CT Perfusion

Treatment:

* tPA / TNK if significant neurologic deficits are present and no contraindications exist* Thrombectomy if large vessel occlusion present without contraindications* Admission to stroke unit to…* Workup the etiology of stroke (usually carotid US, Echo /w bubble study, telemetry monitoring), * Optimize treatment of risk factors such has HLD, HTN, AFib, etc* Obtain early PT/OT/Rehab

Post-tPA Complications: Angioedema (2-5%) and Hemorrhage (2-7%)

* Have a high index of suspicion for hemorrhage – monitor for headaches, change in mental status, signs of ICP, etc* Stop tPA immediately* If concerned for hemorrhage, elevate head of bed and obtain STAT CT Head* For hemorrhage, consider TXA, Platelets, Cryoprecipitate (as recommended by the AHA, however evidence is extremely poor) and consult Neurosurgery* For Angioedema, monitor airway closely, intubate if necessary, and consider medical treatment (FFP, Antihistamines, Steroids, Epinephrine, TXA – all of which have poor evidence for benefit)

Further Reading:

MD Calc- tPA Contraindications

EMDocs – Post tPA Complications

EMRA – Post tPA Hemorrhage