GRAND ROUNDS 07 · DISEASE EDUCATION

Stroke

Acute focal brain ischemia or hemorrhage — time is brain
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Stroke = sudden focal neurologic deficit from a vascular cause. ≈87% ischemic (thrombotic / embolic occlusion) · the rest hemorrhagic (ICH / SAH) — and management diverges entirely. The clock starts at LAST-KNOWN-WELL, not at 911. Reperfuse the salvageable brain before it dies.
1Pathophysiologyocclusion → core + penumbra
1Occlusion — thrombus/embolus blocks a cerebral artery → downstream perfusion collapses.
2Core — center of the territory loses all flow → neurons die in minutes (infarct core, irreversible).
3Penumbra — rim fed by collaterals is stunned but alive & salvageable if flow returns fast.
4Core grows — every minute without reperfusion the penumbra converts to core. ≈1.9 M neurons / min.
5Hemorrhagic path — a vessel ruptures instead → blood in parenchyma (ICH) or subarachnoid space → mass effect + ↑ICP.
2Recognitionscreen fast · call it
BBalance — sudden loss of balance, ataxia, vertigo (posterior clue).
EEyes — sudden vision loss, diplopia, gaze deviation, field cut.
FFace — facial droop; ask them to smile.
AArm — pronator drift / weakness; hold both arms up.
SSpeech — slurred, wrong, or absent words.
TTime — note LAST-KNOWN-WELL, call 911, go to a stroke center. Any positive = act.
3Prehospital Scalesscreen → grade → route
SCALEWHAT IT DOES
CincinnatiFace · Arm · Speech — any 1 abnormal ≈ likely stroke
LAMSFace · arm · grip (0–5); ≥4 suggests LVO
RACE0–9 field scale; ≥5 suggests LVO — bypass to thrombectomy center

A positive LVO screen changes the destination — a clot-retrieval center, not just the nearest ED.

4By Territoryanterior vs posterior
ANTMCA / anterior — hemiparesis, gaze deviation (looks toward the lesion), aphasia (dominant), neglect (non-dominant). Classic LVO picture.
POSTVertebrobasilar — the 5 D's: dizziness, diplopia, dysarthria, dysphagia, dystaxia + crossed signs. The missed-stroke trap — mimics vertigo/intoxication.
6Mimicscheck these before you commit
  • Hypoglycemia
  • Seizure / Todd's palsy
  • Complex migraine
  • Bell's palsy
  • Tumor / mass
  • Conversion / functional
  • Sepsis / metabolic
  • Drug / alcohol tox

Glucose first, every time — hypoglycemia is the great mimic and is instantly reversible.

▲The Penumbracore is dead · the rim is savable
axial ischemic stroke schematic
TIME IS BRAIN — REPERFUSE THE GOLD ZONE core · penumbra · clot
NORMAL perfused brain OCCLUDED ARTERY + CLOT CORE already dead PENUMBRA salvageable — reperfuse fast penumbra converts to core every minute →
≈ 1.9 MILLIONneurons die every minute the artery stays blocked
▲Two Diseasesthe CT decides everything
ISCHEMIC · ≈87%
Clot blocks flow. Reopen the artery: lytics ± thrombectomy.
HEMORRHAGIC · ICH / SAH
Vessel ruptures. Reverse anticoag, lower BP, neurosurgery — no lytics.
5Diagnosticsglucose first · CT rules out blood

Glucose on arrival — hypoglycemia mimics stroke and is instantly fixed. Then the clock work-up:

ANon-contrast CT — the first gate: excludes hemorrhage before any lytic. Early ischemia is often subtle.
BCTA — finds the LVO and maps vessels for thrombectomy.
CCT perfusion / DWI-MRI — sizes core vs penumbra; opens the extended (up to 24 h) window.
DNIHSS — quantify deficit & trend it; ECG, labs, coags, pregnancy test.
▲The Clockwindows shrink · brain shrinks
REPERFUSION WINDOWS FROM LAST-KNOWN-WELL hours · imaging extends
SALVAGEABLE PENUMBRA → becomes dead core IV THROMBOLYSIS tPA / TNK ≤ ≈4.5 h THROMBECTOMY (LVO) extended to 24 h — imaging-selected (DAWN 6–24 h; DEFUSE-3 6–16 h) 0 h LKW 4.5 h 6 h 24 h Faster reperfusion = more brain saved. The window is a ceiling, not a target.
7Treatmentischemic path · per protocol
Last-known-well & glucose first — LKW sets every window; treat hypoglycemia.
BP — permissive. Don't drop it; the penumbra needs pressure. Treat only if >185/110 for a lytic candidate, else >220/120.
Thrombolysis tPA (alteplase) or TNK — within ≈4.5 h of LKW if eligible. CT must exclude bleed first.
Thrombectomy for LVO — to 24 h with favorable perfusion imaging (DAWN 6–24 h; DEFUSE-3 6–16 h). Door→needle ≤60 min · door→groin fast.
Aspirin within 24–48 h — but not before CT and not within 24 h of a lytic.
Supportive: normoglycemia, normothermia, avoid hypoxia, NPO + swallow screen, DVT prophylaxis.
HHemorrhagic Pathopposite playbook
DOWHY
Lower BPReduce hematoma expansion (per protocol target)
ReverseAnticoagulant reversal — vit K/PCC, idarucizumab, andexanet
↓ ICPHead up, normocapnia; neurosurgery / EVD for select ICH/SAH
No lyticsNever tPA / aspirin — you will make the bleed worse

SAH: worst-headache-of-life → CT ± LP; watch for rebleed & vasospasm.

8Critical Proceduresmove brain, not just patients
⚠ Do NOT bleed the penumbra dry
  • CT before aspirin or any lytic — a bleed disguised as a clot is a disaster.
  • Airway for ↓GCS or posterior stroke (bulbar) — protect & support ventilation.
  • Bypass to a thrombectomy center when the field LVO screen is positive — the extra minutes buy neurons.
  • Guard the clock: parallel work-up, pre-notify the stroke team, one nurse owns door-to-needle.
PPitfalls & Pearls
  • Check GLUCOSE — hypoglycemia is the classic stroke mimic.
  • Nail last-known-well — witnessed onset, not discovery, sets the window.
  • Don't drop the BP in ischemic stroke — pressure feeds the penumbra.
  • Posterior strokes get missed — dizzy + diplopia + ataxia is a stroke until proven otherwise.
  • Time = brain — LVO bypass, pre-notify, door-to-needle ≤60 min.
  • Wake-up stroke isn't out — imaging can still open windows.
REMEMBER — BE-FAST: Balance · Eyes · Face · Arm · Speech · Time. Glucose first · CT before lytics · don't drop the BP · reperfuse the gold. Time is brain.
DDisposition
STROKE CENTER / ICU
  • LVO for thrombectomy
  • Post-lytic monitoring (neuro/BP)
  • Any hemorrhage → NSGY
  • Airway / ↓GCS / large infarct
ADMIT / UNIT
  • Stroke unit, telemetry
  • Cause work-up (echo, vessels)
  • Secondary prevention
  • Swallow, PT/OT, rehab
Sheet
Stroke
Series / No.
GRAND ROUNDS 07
Part No.
CC-GR-07
Rev
A
Status
EDUCATION REFERENCE — NOT A PROTOCOL. VERIFY LOCALLY.

SOURCES: AHA/ASA 2019 Guidelines for the Early Management of Acute Ischemic Stroke · DAWN (NEJM 2018) & DEFUSE-3 (NEJM 2018) extended-window thrombectomy · Saver, Time Is Brain—Quantified (Stroke 2006, ~1.9 M neurons/min) · AHA BE-FAST public-education campaign; Tintinalli, Emergency Medicine. Windows/doses educational — not medical advice & not a protocol; reference for trained clinicians only. Verify all drugs, doses & treatments against local protocol & current guidelines. Full disclaimer: crashcard.co/legal. © 2026 Claustrum LLC d/b/a Crash Card · crashcard.co · Printed in Minnesota.