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Ischemic stroke

Last updated: September 27, 2021

Summarytoggle arrow icon

Ischemic stroke is an acute neurological condition caused by impaired cerebral blood flow (e.g., vascular occlusion or systemic hypoperfusion). The most important risk factors are chronic systemic hypertension and cardiovascular disease. Clinically, ischemic stroke is characterized by the acute onset of focal neurological deficits, which are dependent on the cerebral territory covered by the relevant vessel. If ischemic stroke is suspected, a noncontrast head CT should immediately be performed to rule out intracranial hemorrhage and blood glucose should be measured as it is a stroke mimic. Revascularization of the vessels affected in ischemic stroke, e.g., via tissue plasminogen activator (tPA) or thrombectomy, can preserve brain tissue and improve outcomes if given early. Further treatment consists of supportive care, neuroprotective measures, management of underlying causes, and secondary prevention with antiplatelet therapy and treatment of modifiable risk factors (i.e., hypertension, atherosclerosis).

Recommendations in this article are primarily consistent with the 2019 American Heart Association (AHA) guidelines for the early management of patients with acute ischemic stroke and the 2021 AHA guidelines for secondary stroke prevention. [1][2]

Transient ischemic attack, intracerebral hemorrhage, and subarachnoid hemorrhage are covered in separate articles. See also “Overview of stroke.”

For both ischemic and hemorrhagic strokes, age is the most important nonmodifiable risk factor and arterial hypertension is the most important modifiable risk factor!

References:[3][4][5]

Epidemiological data refers to the US, unless otherwise specified.

References:[4][6][7][8][9][10][11][12][13]

Patterns of necrosis in ischemic stroke [14]

Infarction of brain tissue is typically followed by liquefactive necrosis, in contrast to the coagulative necrosis seen after infarction in other organs.

Selective neuronal necrosis

Pannecrosis

  • Definition: the death of all cell types in a given region of the brain, including neurons, glial cells, and vascular cells
  • Mechanism: permanent ischemia
  • Histology: cystic lesions and loss of tissue architecture

Histologic changes in the infarcted region [14][15]

Time from start of ischemia Histologic features
12–24 hours
1–3 days
3–5 days
5–15 days
> 15 days

To recall the areas most vulnerable to hypoxia: Vulnerable hippos Need PURe water (hippocampus, Neocortex, PURkinje cells, and watershed areas).

References:[14][15]

Stroke should be ruled out in patients presenting with first-time epileptic seizures and subsequent neurological deficits, as the seizure may have been caused by an acute cerebral pathology.

The differential diagnoses listed here are not exhaustive.

Primary survey

Clinical assessment and management should occur simultaneously with the goals of stabilizing the patient, keeping the door-to-neuroimaging time to a minimum, and identifying candidates for reperfusion therapy as soon as possible. [1][16][17]

Only POC glucose and noncontrast neuroimaging (e.g., CT head or MR brain) are required prior to thrombolytic therapy. Do not delay treatment to complete the remainder of the diagnostic evaluation. A classic clinical presentation without evidence of a stroke mimic or intracranial bleeding on initial neuroimaging is typically enough to diagnose acute ischemic stroke in time-limited settings. [1]

Malignant infarctions in the MCA territory or large PICA infarctions may require surgical intervention before edema reaches its maximum extent to prevent brain herniation. [1]

Blood pressure management in acute ischemic stroke [1]

The following scales can be calculated at initial presentation to guide treatment decisions and estimate prognosis, or repeated to monitor progression and response to therapy during admission, rehabilitation, and follow-up. They are also used as outcome measures in clinical trials.

National Institutes of Health Stroke Scale (NIHSS) [19]

  • A severity score that quantifies neurological impairment for specific categories within the following broad domains:
  • Scores between are assigned for each category are combined and totals can range from 0 (no impairment) to 42 (most severe).

The NIHSS is weighted towards anterior circulation strokes and underestimates stroke severity in the posterior circulation. [20]

National Institute of Health Stroke Scale (NIHSS) [1][19]
Category Task Score
1a: Level of consciousness

Assess alertness.

1b: Orientation questions

Ask month and age.

  • 0: Answers both correctly
  • 1: Answers one correctly
  • 2: Answers neither question correctly

1c: Commands

Patient opens/closes eyes and makes a fist.

  • 0: Follows both commands [19]
  • 1: Follows one command
  • 2: Does not follow commands

2: Gaze

Patient follows examiner's finger in horizontal movements.

  • 0: Normal movement
  • 1: Partial gaze palsy
  • 2: Forced deviation or complete gaze palsy

3: Visual fields

Present visual stimuli in the patient's visual field quadrants.

4: Facial palsy

Patient shows teeth, raises eyebrows, squeezes eyes shut.

  • 0: Normal movement
  • 1: Minor facial paralysis
  • 2: Partial facial paralysis
  • 3: Complete unilateral or bilateral facial paralysis

5a: Motor: left arm

5b: Motor: right arm

Patient elevates each arm to 45° from a supine position or 90° if sitting with open palms facing downwards.

  • 0: No drift
  • 1: Arm drifts within 10 seconds
  • 2: Arm falls within 10 seconds but shows some effort against gravity
  • 3: Arm falls; no effort possible against gravity
  • 4: No movement

(Separate scores are given for left arm and right arm.)

6a: Motor: left leg

6b: Motor: right leg

Patient elevates each leg to 30° from a supine position.

  • 0: No drift
  • 1: Leg drifts within 5 seconds
  • 2: Leg falls within 5 seconds but shows some effort against gravity
  • 3: Leg falls; no effort possible against gravity
  • 4: No movement

(Separate scores are given for left leg and right leg.)

7: Limb ataxia

Patient performs finger-to-nose and heel-shin tests on both sides.

8: Sensory

Test sensation of face, arms, and legs.

  • 0: Normal sensation
  • 1: Mild sensory loss
  • 2: Severe sensory loss

9: Language

Patient names items, describes a picture, or reads a sentence.

10: Dysarthria

Ask patient to read or repeat words.

11: Sensory extinction or inattention

Offer simultaneous tactile and visual stimuli.

  • 0: No extinction or inattention
  • 1: Extinction or inattention in one sensory modality
  • 2: Complete inattention to one side or extinction to ≥ 1 sensory modality
  • Instructions
    • Assess each category in order.
    • Score only what the patient does, without making assumptions about their capabilities.
    • Do not coach the patient or change scores retroactively.
  • Interpretation: There is currently no consensus on which NIHSS scores serve as cutoffs for stroke severity. [21]
    • Minor stroke is most commonly defined as NIHSS ≤ 5 or NIHSS ≤ 3. [1][21][22][23]
    • Very severe stroke is defined by the 2019 AHA guideline as NIHSS > 25. [1]
    • Can also be used to assess prognosis, although cutoffs vary. [17][24][25]

Modified Rankin scale [26][27]

  • A scale used to quantify the degree of disability and dependence in daily activities before and after cerebral stroke.
  • The scale ranges from 0 (no symptoms) to 6 (death).
Modified Rankin scale
Disability Symptoms Score
None Absent 0
Insignificant Present, but not affecting usual activities 1
Slight Affecting some activities, but not affecting independence 2
Moderate Necessitating assistance for some ADLs, but not for walking 3
Moderately severe Necessitating assistance for walking and most ADLs 4
Severe Necessitating full-time care for all ADLs (e.g., bedbound, incontinent) 5
Death 6

Diagnostic approach [2][28][29][30]

Obtain noncontrast neuroimaging as soon as possible.

The decision to obtain advanced imaging should not delay the administration of thrombolytic therapy in appropriate candidates. [1]

Immediate laboratory studies [1][2][13][32]

Cardiac evaluation [1][2]

All patients with a suspected ischemic stroke should receive an initial ECG and cardiac monitoring.

Additional investigations [1][13][32]

Consider these in select patients, e.g., to identify the underlying cause, assess the risk of recurrence, and evaluate comorbidities or complications.

Noncontrast CT head [29][30][37][38][39]

Infarctions in the cerebellum and brainstem may be harder to detect with noncontrast head CT than infarctions in other regions. [43]

MRI brain [1][37][44]

DWI-FLAIR mismatch indicates hyperacute ischemic stroke that occurred within the past 6 hours. [46]

Neurovascular studies [1][2][13]

In potential candidates for mechanical thrombectomy, perform CTA immediately following noncontrast CT. If indicated, thrombolysis can be performed simultaneously. [1]

If indicated, do not delay CTA to wait for creatinine or TSH levels, as the risk of iodine-induced hyperthyroidism and contrast-induced nephropathy is relatively low, especially in patients with no known history of thyroid or renal abnormalities. [35][39][52][53]

Therapeutic approach [1]

General principles [1]

Time is brain! Reperfusion therapy should not be delayed. However, intracranial hemorrhage is a contraindication for reperfusion therapy and must be ruled out first.

Intravenous thrombolysis [1]

Inclusion and exclusion criteria for thrombolysis are not strict and treatment decisions should be made in consultation with a neurologist taking into account multiple individual patient factors.

If a patient is unable to consent to treatment (e.g., altered mental status, aphasia) and a legal representative is not immediately present, IV alteplase can still be administered in eligible patients with disabling stroke symptoms. [1]

Do not wait on coagulation parameters before administering tPA in patients with no known history of coagulopathy or thrombocytopenia. Discontinue treatment if platelets are < 100,000/mm3, INR > 1.7 or PT is abnormally elevated. [1]

Exclusion criteria for thrombolysis in acute ischemic stroke [1]

Absolute contraindications

Relative contraindications

Preexisting conditions
Acute findings

Some conditions commonly misconceived as contraindications for thrombolysis therapy include antiplatelet therapy, end-stage renal disease, and concurrent MI. In patients with preexisting disability or dementia, treatment decisions should be based on prestroke functionality and quality of life. [1]

Severe hypo- or hyperglycemia (glucose < 50 mg/dL or > 400 mg/dL) and severe hypertension > 185/110 mm Hg should be treated before tPA administration. [1]

Complications of IV thrombolytic therapy [1]

Additional measures after thrombolysis

  • Check blood pressure and neurological status frequently.
  • Avoid invasive procedures, if possible.
  • Obtain a follow-up head CT (without IV contrast) or brain MRI 24 hours after thrombolysis, prior to starting anticoagulants or antiplatelet agents.

Mechanical thrombectomy [1]

Patients who are eligible for tPA should receive thrombolysis immediately, while mechanical thrombectomy is being considered. If indicated, mechanical thrombectomy should be performed without delay to assess the response to thrombolysis. [1]

Neuroprotective measures

Follow standard measures, including the following specific targets for acute ischemic stroke: [1]

Supportive care

Further therapeutic goals consist of identifying and treating risk factors and underlying conditions to prevent recurrent stroke. [1][32]

Antiplatelet therapy [1][2][32]

Wait at least 24 hours before initiating antiplatelet treatment after thrombolysis.

Management of underlying causes [1][2][32]

Treatment of modifiable risk factors [2]

The single most important treatable risk factor for secondary stroke prevention is hypertension.

Initial evaluation

After stabilization

We list the most important complications. The selection is not exhaustive.

Primary stroke prevention [59]

Management of modifiable risk factors decreases the likelihood of a first stroke. [60]

Lacunar infarct [9][61]

Infarction of the posterior limb of the internal capsule is the most common type of lacunar stroke and may manifest clinically with pure motor stroke, pure sensory stroke (rare), sensorimotor stroke, dysarthria-clumsy hand syndrome, and/or ataxic hemiparesis.

Watershed infarct [4][62]

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  1. Kernan WN, Ovbiagele B, Black HR et al. Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack. Stroke. 2014; 45 (7): p.2160-2236. doi: 10.1161/STR.0000000000000024 . | Open in Read by QxMD
  2. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019; 50 (12). doi: 10.1161/str.0000000000000211 . | Open in Read by QxMD
  3. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021 . doi: 10.1161/str.0000000000000375 . | Open in Read by QxMD
  4. Prasad K, Siemieniuk R, Hao Q, et al. Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline. BMJ. 2018; 363 : p.k5130. doi: 10.1136/bmj.k5130 . | Open in Read by QxMD
  5. Hackam DG, Spence JD. Antiplatelet Therapy in Ischemic Stroke and Transient Ischemic Attack. Stroke. 2019; 50 (3): p.773-778. doi: 10.1161/strokeaha.118.023954 . | Open in Read by QxMD
  6. Lansberg MG, O’Donnell MJ, Khatri P, et al. Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141 (2): p.e601S-e636S. doi: 10.1378/chest.11-2302 . | Open in Read by QxMD
  7. Winstein CJ, Stein J, Arena R, et al. Guidelines for Adult Stroke Rehabilitation and Recovery. Stroke. 2016; 47 (6). doi: 10.1161/str.0000000000000098 . | Open in Read by QxMD
  8. Stroke Facts. https://www.cdc.gov/stroke/facts.htm. Updated: December 30, 2016. Accessed: March 28, 2017.
  9. Caplan LR, Kasner SE, Dashe JF. Etiology, Classification, and Epidemiology of Stroke. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/etiology-classification-and-epidemiology-of-stroke.Last updated: March 14, 2017. Accessed: March 28, 2017.
  10. Appelros P, Stegmayr B, Terént A. Sex differences in stroke epidemiology: a systematic review. Stroke. 2009; 40 (4). doi: 10.1161/STROKEAHA.108.540781 . | Open in Read by QxMD
  11. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. McGraw-Hill Education ; 2015
  12. Agabegi SS, Agabegi ED. Step-Up To Medicine. Wolters Kluwer Health ; 2015
  13. Le T, Bhushan V, Skelley N. First Aid for the USMLE Step 2 CK. McGraw-Hill Education ; 2012
  14. Oliveira Filho J. Lacunar infarcts. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/lacunar-infarcts.Last updated: March 9, 2017. Accessed: March 28, 2017.
  15. Furie KL, Rost NS. Overview of secondary prevention of ischemic stroke. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/overview-of-secondary-prevention-of-ischemic-stroke.Last updated: September 1, 2016. Accessed: March 28, 2017.
  16. Oliveira Filho J, Mullen MT. Initial assessment and management of acute stroke. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke.Last updated: August 15, 2016. Accessed: March 29, 2017.
  17. Yew KS, Cheng EM. Diagnosis of Acute Stroke. Am Fam Physician. 2015; 91 (8): p.528-536.
  18. EC J, JL S, Jr AH, et al.. Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke. 2013; 44 (3): p.870-947. doi: 10.1161/STR.0b013e318284056a . | Open in Read by QxMD
  19. De Lucas EM, Sánchez E, Gutiérrez A, et al. CT Protocol for Acute Stroke: Tips and Tricks for General Radiologists. RadioGraphics. 2008; 28 (6): p.1673-1687. doi: 10.1148/rg.286085502 . | Open in Read by QxMD
  20. Tomandl BF, Klotz E, Handschu R, et al. Comprehensive Imaging of Ischemic Stroke with Multisection CT. RadioGraphics. 2003; 23 (3): p.565-592. doi: 10.1148/rg.233025036 . | Open in Read by QxMD
  21. Srinivasan A, Goyal M, Azri FA, Lum C. State-of-the-Art Imaging of Acute Stroke. RadioGraphics. 2006; 26 : p.S75-S95. doi: 10.1148/rg.26si065501 . | Open in Read by QxMD
  22. Mayer SA, Viarasilpa T, Panyavachiraporn N, et al. CTA-for-All. Stroke. 2020; 51 (1): p.331-334. doi: 10.1161/strokeaha.119.027356 . | Open in Read by QxMD
  23. Morris JG, Duffis EJ, Fisher M. Cardiac Workup of Ischemic Stroke. Stroke. 2009; 40 (8): p.2893-2898. doi: 10.1161/strokeaha.109.551226 . | Open in Read by QxMD
  24. Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease.. Stroke. 2009; 40 (6): p.2276-93. doi: 10.1161/STROKEAHA.108.192218 . | Open in Read by QxMD
  25. Davenport M, Wang C, Asch D. ACR Manual on Contrast Media. American College of Radiology ; 2021
  26. Curry NS, Davenport R, Pavord S, et al. The use of viscoelastic haemostatic assays in the management of major bleeding. Br J Haematol. 2018; 182 (6): p.789-806. doi: 10.1111/bjh.15524 . | Open in Read by QxMD
  27. Venkataraman P, Lui F. Lacunar Syndromes. StatPearls. 2018 .
  28. Standring S. Gray's Anatomy: The Anatomical Basis of Clinical Practice. Elsevier Health Sciences ; 2016
  29. Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the Primary Prevention of Stroke. Stroke. 2014; 45 (12): p.3754-3832. doi: 10.1161/str.0000000000000046 . | Open in Read by QxMD
  30. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. J Am Coll Cardiol. 2019; 74 (10): p.e177-e232. doi: 10.1016/j.jacc.2019.03.010 . | Open in Read by QxMD
  31. Goljan EF. Rapid Review Pathology. Elsevier Saunders ; 2018
  32. Mena H, Cadavid D, Rushing EJ. Human cerebral infarct: a proposed histopathologic classification based on 137 cases. Acta Neuropathol. 2004; 108 (6): p.524-530. doi: 10.1007/s00401-004-0918-z . | Open in Read by QxMD
  33. NIH Stroke Scale. https://www.stroke.nih.gov/resources/scale.htm. . Accessed: September 15, 2020.
  34. Meyer BC, Lyden PD. The Modified National Institutes of Health Stroke Scale: its Time has Come. International Journal of Stroke. 2009; 4 (4): p.267-273. doi: 10.1111/j.1747-4949.2009.00294.x . | Open in Read by QxMD
  35. Fischer U, Baumgartner A, Arnold M, et al. What Is a Minor Stroke?. Stroke. 2010; 41 (4): p.661-666. doi: 10.1161/strokeaha.109.572883 . | Open in Read by QxMD
  36. Haydel MJ, Garmel GM. Appendix A Clinical decision rules and guidelines. In: V. Mahadevan S, Garmel GM, eds. An Introduction to Clinical Emergency Medicine. Cambridge University Press ; 2012.
  37. Adams HP, Davis PH, Leira EC, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999; 53 (1): p.126-126. doi: 10.1212/wnl.53.1.126 . | Open in Read by QxMD
  38. Frankel MR, Morgenstern LB, Kwiatkowski T, et al. Predicting prognosis after stroke: A placebo group analysis from the National Institute of Neurological Disorders and Stroke rt-PA Stroke Trial. Neurology. 2000; 55 (7): p.952-959. doi: 10.1212/wnl.55.7.952 . | Open in Read by QxMD
  39. Wouters A, Nysten C, Thijs V, Lemmens R. Prediction of Outcome in Patients With Acute Ischemic Stroke Based on Initial Severity and Improvement in the First 24 h. Frontiers in Neurology. 2018; 9 . doi: 10.3389/fneur.2018.00308 . | Open in Read by QxMD
  40. Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients.. Stroke. 1988; 19 (5): p.604-607. doi: 10.1161/01.str.19.5.604 . | Open in Read by QxMD
  41. Fearon P, McArthur KS, Garrity K, et al. Prestroke Modified Rankin Stroke Scale Has Moderate Interobserver Reliability and Validity in an Acute Stroke Setting. Stroke. 2012; 43 (12): p.3184-3188. doi: 10.1161/strokeaha.112.670422 . | Open in Read by QxMD
  42. Catanese L, Tarsia J, Fisher M. Acute Ischemic Stroke Therapy Overview. Circ Res. 2017; 120 (3): p.541-558. doi: 10.1161/circresaha.116.309278 . | Open in Read by QxMD
  43. González RG, Hirsch JA, Lev MH, Schaefer PW, Schwamm LH. Acute Ischemic Stroke. Springer Science & Business Media ; 2010
  44. Potter CA, Vagal AS, Goyal M, Nunez DB, Leslie-Mazwi TM, Lev MH. CT for Treatment Selection in Acute Ischemic Stroke: A Code Stroke Primer. RadioGraphics. 2019; 39 (6): p.1717-1738. doi: 10.1148/rg.2019190142 . | Open in Read by QxMD
  45. Geyer JD, Gomez CR. Stroke. Lippincott Williams & Wilkins ; 2009 : p. 263
  46. Dostovic Z, Dostovic E, Smajlovic D, Avdic O. Brain Edema After Ischaemic Stroke. Medical Archives. 2016; 70 (5): p.339. doi: 10.5455/medarh.2016.70.339-341 . | Open in Read by QxMD
  47. Wardlaw JM. RADIOLOGY OF STROKE. Journal of Neurology, Neurosurgery & Psychiatry. 2001; 70 (90001): p.7i-11. doi: 10.1136/jnnp.70.suppl_1.i7 . | Open in Read by QxMD
  48. Hwang DY, Silva GS, Furie KL, Greer DM. Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting acute posterior fossa infarct.. J Emerg Med. 2012; 42 (5): p.559-65. doi: 10.1016/j.jemermed.2011.05.101 . | Open in Read by QxMD
  49. Mandell J. Core Radiology. Cambridge University Press ; 2013
  50. Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. The Lancet. 2007; 369 (9558): p.293-298. doi: 10.1016/s0140-6736(07)60151-2 . | Open in Read by QxMD
  51. Allen LM, Hasso AN, Handwerker J, Farid H. Sequence-specific MR Imaging Findings That Are Useful in Dating Ischemic Stroke. RadioGraphics. 2012; 32 (5): p.1285-1297. doi: 10.1148/rg.325115760 . | Open in Read by QxMD
  52. Kang D-W, Chalela JA, Ezzeddine MA, Warach S. Association of Ischemic Lesion Patterns on Early Diffusion-Weighted Imaging With TOAST Stroke Subtypes. Arch Neurol. 2003; 60 (12): p.1730. doi: 10.1001/archneur.60.12.1730 . | Open in Read by QxMD
  53. Copen WA, Schaefer PW, Wu O. MR Perfusion Imaging in Acute Ischemic Stroke. Neuroimaging Clin N Am. 2011; 21 (2): p.259-283. doi: 10.1016/j.nic.2011.02.007 . | Open in Read by QxMD
  54. Vagal A, Wintermark M, Nael K, et al. Automated CT perfusion imaging for acute ischemic stroke. Neurology. 2019 : p.10.1212/WNL.0000000000008481. doi: 10.1212/wnl.0000000000008481 . | Open in Read by QxMD
  55. Mazya MV, Ahmed N, Azevedo E, et al. Impact of Transcranial Doppler Ultrasound on Logistics and Outcomes in Stroke Thrombolysis. Stroke. 2018; 49 (7): p.1695-1700. doi: 10.1161/strokeaha.118.021485 . | Open in Read by QxMD
  56. Latchaw RE, Alberts MJ, Lev MH, et al. Recommendations for Imaging of Acute Ischemic Stroke. Stroke. 2009; 40 (11): p.3646-3678. doi: 10.1161/strokeaha.108.192616 . | Open in Read by QxMD
  57. Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016; 26 (10): p.1343-1421. doi: 10.1089/thy.2016.0229 . | Open in Read by QxMD
  58. Brinjikji W, Demchuk AM, Murad MH, et al. Neurons Over Nephrons. Stroke. 2017; 48 (7): p.1862-1868. doi: 10.1161/strokeaha.117.016771 . | Open in Read by QxMD
  59. Burgos AM, Saver JL. Evidence that Tenecteplase Is Noninferior to Alteplase for Acute Ischemic Stroke. Stroke. 2019; 50 (8): p.2156-2162. doi: 10.1161/strokeaha.119.025080 . | Open in Read by QxMD
  60. Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke. 2016; 47 (2): p.581-641. doi: 10.1161/str.0000000000000086 . | Open in Read by QxMD
  61. Brott T, Adams HP, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale.. Stroke. 1989; 20 (7): p.864-870. doi: 10.1161/01.str.20.7.864 . | Open in Read by QxMD
  62. Shah S, Luby M, Poole K, et al. Screening with MRI for Accurate and Rapid Stroke Treatment: SMART. Neurology. 2015; 84 (24): p.2438-2444. doi: 10.1212/wnl.0000000000001678 . | Open in Read by QxMD
  63. Cucchiara BL, Messé SR. Antiplatelet therapy for secondary prevention of stroke. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/antiplatelet-therapy-for-secondary-prevention-of-stroke.Last updated: July 25, 2016. Accessed: February 20, 2017.
  64. Schur PH, Kaplan AA. Treatment of antiphospholipid syndrome. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/treatment-of-antiphospholipid-syndrome.Last updated: February 23, 2017. Accessed: April 3, 2017.
  65. Louis R Caplan. Overview of the Evaluation of Stroke. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-the-evaluation-of-stroke?search=overview%20of%20the%20evaluation%20of%20stroke&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.Last updated: February 14, 2019. Accessed: April 1, 2019.
  66. Warren J Manning, Daniel E singer, Gregory YH Lip. Atrial fibrillation: Anticoagulant therapy to prevent thromboembolism. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/atrial-fibrillation-anticoagulant-therapy-to-prevent-thromboembolism?source=autocomplete&index=0~4&search=atrial%20fibrillation:.Last updated: July 24, 2018. Accessed: April 1, 2019.
  67. Sorensen AG, Ay H. Transient ischemic attack: definition, diagnosis, and risk stratification.. Neuroimaging Clin N Am. 2011; 21 (2): p.303-13, x. doi: 10.1016/j.nic.2011.01.013 . | Open in Read by QxMD
  68. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. Chest. 2016; 149 (2): p.315-352. doi: 10.1016/j.chest.2015.11.026 . | Open in Read by QxMD
  69. Porth C, Matfin G. Pathophysiology. Lippincott Williams & Wilkins ; 2009
  70. Harbison J, Hossain O, Jenkinson D, Davis J, Louw SJ, Ford GA. Diagnostic Accuracy of Stroke Referrals From Primary Care, Emergency Room Physicians, and Ambulance Staff Using the Face Arm Speech Test. Stroke. 2003; 34 (1): p.71-76. doi: 10.1161/01.str.0000044170.46643.5e . | Open in Read by QxMD
  71. Smith EE, Kent DM, Bulsara KR, et al. Accuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Individuals With Suspected Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke. 2018; 49 (3). doi: 10.1161/str.0000000000000160 . | Open in Read by QxMD
  72. NIHSS MD Calc. https://www.mdcalc.com/nih-stroke-scale-score-nihss. . Accessed: March 2, 2020.
  73. Thomalla G, Simonsen CZ, Boutitie F, et al. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset. N Engl J Med. 2018; 379 (7): p.611-622. doi: 10.1056/nejmoa1804355 . | Open in Read by QxMD
  74. Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med. 2018; 378 (1): p.11-21. doi: 10.1056/nejmoa1706442 . | Open in Read by QxMD
  75. Albers GW, Marks MP, Kemp S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. N Engl J Med. 2018; 378 (8): p.708-718. doi: 10.1056/nejmoa1713973 . | Open in Read by QxMD
  76. Hirai T, Korogi Y, Ono K, et al. Prospective evaluation of suspected stenoocclusive disease of the intracranial artery: combined MR angiography and CT angiography compared with digital subtraction angiography.. AJNR Am J Neuroradiol. 2002; 23 (1): p.93-101.
  77. Bash S, Villablanca JP, Jahan R, et al. Intracranial vascular stenosis and occlusive disease: evaluation with CT angiography, MR angiography, and digital subtraction angiography.. AJNR Am J Neuroradiol. 2005; 26 (5): p.1012-21.
  78. Goyal M, Demchuk AM, Menon BK, et al. Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. N Engl J Med. 2015; 372 (11): p.1019-1030. doi: 10.1056/nejmoa1414905 . | Open in Read by QxMD
  79. Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke. N Engl J Med. 2015; 372 (24): p.2296-2306. doi: 10.1056/nejmoa1503780 . | Open in Read by QxMD
  80. Saver JL, Goyal M, Bonafe A, et al. Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. N Engl J Med. 2015; 372 (24): p.2285-2295. doi: 10.1056/nejmoa1415061 . | Open in Read by QxMD
  81. Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. N Engl J Med. 2015; 372 (11): p.1009-1018. doi: 10.1056/nejmoa1414792 . | Open in Read by QxMD
  82. Berkhemer OA, Fransen PSS, Beumer D, et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. N Engl J Med. 2015; 372 (1): p.11-20. doi: 10.1056/nejmoa1411587 . | Open in Read by QxMD
  83. Kasner SE. Clinical interpretation and use of stroke scales. The Lancet Neurology. 2006; 5 (7): p.603-612. doi: 10.1016/s1474-4422(06)70495-1 . | Open in Read by QxMD
  84. Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. The Lancet. 2000; 355 (9216): p.1670-1674. doi: 10.1016/s0140-6736(00)02237-6 . | Open in Read by QxMD
  85. Thomalla G, Cheng B, Ebinger M, et al. DWI-FLAIR mismatch for the identification of patients with acute ischaemic stroke within 4·5 h of symptom onset (PRE-FLAIR): a multicentre observational study. The Lancet Neurology. 2011; 10 (11): p.978-986. doi: 10.1016/s1474-4422(11)70192-2 . | Open in Read by QxMD
  86. Johnston SC, Easton JD, Farrant M, et al. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. N Engl J Med. 2018; 379 (3): p.215-225. doi: 10.1056/nejmoa1800410 . | Open in Read by QxMD
  87. Parker S, Ali Y. Changing contraindications for t-PA in acute stroke: review of 20 years since NINDS.. Curr Cardiol Rep. 2015; 17 (10): p.81. doi: 10.1007/s11886-015-0633-5 . | Open in Read by QxMD
  88. Fugate JE, Rabinstein AA. Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke. The Neurohospitalist. 2015; 5 (3): p.110-121. doi: 10.1177/1941874415578532 . | Open in Read by QxMD