Stroke Code Algorithm

1 Last known well and first steps

• Establish last known well (not when symptoms were found)
• Glucose (treat under 60), NIHSS, IV access
• CT head without contrast within 20 minutes of arrival; CTA for large-vessel occlusion

CT shows hemorrhage → step 2No hemorrhage → step 3

2 Intracerebral hemorrhage

• Reverse anticoagulants now
• SBP target about 140 (avoid under 130); smooth control
• Neurosurgery consult; HOB 30°; seizure and ICP watch

End of this path.

3 Within 4.5 hours of last known well?

Yes → step 4No, or unknown (wake-up) → step 5

4 Thrombolysis

• Tenecteplase 0.25 mg/kg single bolus (max 25 mg), or alteplase 0.9 mg/kg (max 90 mg): 10% bolus, rest over 60 minutes
• BP under 185/110 before, under 180/105 for 24 hours after
• Door-to-needle goal 60 minutes or less (45 or less ideal)
• Neuro checks and BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly

Large-vessel occlusion on CTA → step 6

5 Beyond 4.5 hours or wake-up stroke

• MRI DWI–FLAIR mismatch or perfusion imaging may still allow a lytic
• Large-vessel occlusion: thrombectomy up to 24 hours with favorable imaging

Large-vessel occlusion → step 6

6 Endovascular thrombectomy

• Activate the neurointerventional team; do not wait to see if the lytic works
• Large cores can still benefit (recent trials)
• BP 180/105 or less after; avoid aggressive lowering after successful recanalization

End of this path.