- BP 

- uncontrolled blood glucose (A1C):
need insulin therapy

- Further management for kidney function: [BUN and Creatinine clearance (65 ml/min)] 

- Hemoglobin 

- Coagulation factors 

B- GoT:

-To reduce the ongoing neurologic injury and decrease mortality and long‐term disability

-Determining if patients with acute ischemic stroke are candidates for thrombolytic therapy

-Prevent complications secondary to immobility and neurologic dysfunction

-Prevent stroke recurrence

C- To qualify for tPA, BP must be maintained below 180/105 [need alteplase]

D-  Labetalol 10 mg IV for 1 minutes, then double the dose every 10 minutes to lower it by 10-15% reduction in BP, and monitor.
If BP still high during TPA ,give nitroprusside 0.5 mcg/kg/min IV.

B- He is eligible. 

Alteplase dose: 6.75 mg IV bolus then 67.5 IV infusion for the remaining of the one hour.

C- streptokinase has high rate of hemorrhage – reteplase & urukinase & anistreplase & staphylokinase have not been tested extensively. Tenecteplace appears promising. 

D- Monitor: 

- minor/major Bleeding

- BP and vitals q15min
- glucose level

- neurologic function q15min x 2 hr, then q30min x 6hr
- side effects such as :GIT disturbance symptoms, headache. If severe symptoms occur, discontinue the infusion. 

- Obtain a follow-up CT scan or MRI at 24 hours before starting anticoagulants or antiplatelet agents

E-  blood pressure and blood glucose management during the first 24 hrs.

Blood pressure agents

Cholesterol monitoring and smoking cessation. 

Diet and diabetes need further management to keep glucose within the normal range.

Education and Exercise.  

B- In patients presenting with minor stroke, treatment for 21 days with dual antiplatelet therapy (aspirin and clopidogrel) begun within 24 hours can be beneficial for early secondary stroke prevention for a period of up to 90 days from symptom onset (The CHANCE trial: The primary outcome of recurrent stroke at 90 days (ischemic or

hemorrhagic) favored dual antiplatelet therapy over aspirin alone)
[Not for long-term management]

C- “ secondary prevention measures are appropriately instituted within the first 2 weeks” (AHA 2018).

D- Safety: prevent/monitor side effects: GI upset - toxicity - muscle pain - bleeding - ... 
Efficacy: Prevent recurrence of stroke - monitor patient's symptoms - ... 

decrease mortality and long‐term disability 
2. Determining if patients with acute ischemic 

stroke are candidates for thrombolytic therapy 
3. Prevent complications secondary to immobility 

and neurologic dysfunction 
4. Prevent stroke recurrence

D) Labetalol 10- 20 mg IV for 1-2 minutes, then double the dose every 10 mins, to lower by 10-15% of BP. If this fails and BP is still elevated during or after tx, give Nitroprusside add on

Perform CT scan and MRI to determine type of stroke 

C) CT scan
D) ECG, TTE, TEE, blood glucose test, electrolytes, CBC, renal function, cardiac biomarkers, 

C) 
D)neurologic assessment every 15 minutes for 2 hours and then
every 30 minutes for 6 hours to include monitoring for signs and
symptoms of intracerebral hemorrhage (ICH) (
– decrease in the level of consciousness or worsening neurologic
deficit occurs during infusion, notify the physician and stop the
infusion
– monitored for gastrointestinal or genitourinary hemorrhage
– Monitor BP as
E)  control BP, glucose, prevention management

C)  - CT scan to rule out hemorrhagic stroke 

- MRI (DWI and PWI for extent of ischemia) 

- Blood glucose test to rule out hypoglycemia

D)  

- TTE for valve abnormalities to find source of stroke
-  ECG (to determine presence of Afib)

BP monitoring 

Assess eligibility for Tpa 

Uncontrolled coagulation 

Uncontrolled blood glucose 

DVT Prophylaxis 
monitor for neurological deterioration 

B)  

·         Reduce infarct size 

·         Reduce mortality 

·         Reduce ongoing neurological injury 

·         Reduce long term disability 

·         Determine if patient is candidate to repurfusion 

·         Prevent complications secondary to immobility and  neurologic dysfunction 

·         Prevent stroke reccurence 

C) If tPA eligible <185/110mmHg

If not then lower than 220/120mmHg

  

D) Labetalol 5mg IV for 1 minute then double the dose every 10minutes to lower it by 10-15% reduction in BP 

OR 

Nicardipine 5mg per hour IV then titrate to 2.5mg for 1 hour every 5 minutes max. 15mg 10-15% reduction in BP 

OR 

Nitroprusside 0.5ug/kg/minute to target 10-15% reduction in BP 

·         IV alteplase 0.9mg/kg (67.5mg). 10% (6.75mg) as IV bolus within 1 minute and 90% (60.75mg) within the next hour 

B) ·         Inclusion: 

o   Time within 4.5hr of symptoms onset

o   >18yo

o   Evidence of ischemic stroke

·         Exclusion:

o   Taking anticoagulants

o   Hemorrhagic stroke

o   History of stroke in the previous 3 months 

o   Intracranial hemorrhage 

·         0.9mg/kg (67.5mg). 10% (6.75mg) as IV bolus within 1 minute and 90% (60.75mg) within the next hour

C)  

·         Streptokinase= increase hemorrhage (high rates of hemorrhage) 

·         Urokinase, reteplase, anistreplase, staphylokinase= not studied/tested 

·         Tenectoplase= long half life and higher fibrin specificity but still being studied yet shows promising effects 

·         Desmoteplase= phase III studies still in place 

D) 
* efficacy:
- monitor for  neurological function every 15minutes for 2hrs
then check safety:
- by neurologic function every 30min for 6hr to check for intracranial hemorrhage 
- GI bleeding
-BP
E)  

·         IV tenecteplase 0.4mg/kg bolus 

·         OR Anticoagulant (DOAC) (not cardioembolic)

·         Blood pressure (recontinue bisoprolol) <140/90

·         Diabetes (reassess metformin) HbA1c<6.5% 

·         Statins (change to Atorvastatin 80mg) <1.4mmol LDL
b) Only recommended for TIA as per CHANCE trial with NIHSS score of less than 3
c) 24hrs after admission