A stroke is a sudden loss of neurologic function caused by interrupted blood flow to part of the brain. Brain tissue survives only minutes without oxygen and glucose, so treatment is time-dependent: "time is brain."

Types

Risk factors: hypertension (the most important modifiable factor), atrial fibrillation, diabetes, smoking, dyslipidemia, obesity, physical inactivity, heavy alcohol use, prior stroke or TIA, sickle cell disease, and oral contraceptives combined with smoking.

Deficits depend on location. A left-hemisphere stroke affects the right side of the body and usually language; a right-hemisphere stroke affects the left side and spatial perception.

Unilateral neglect is failure to recognize or attend to the affected side of the body and space — the client may eat from only half the plate or ignore the affected arm. Homonymous hemianopia is loss of the same half of the visual field in both eyes.

Sudden onset of any of the following (BE FAST):

• Balance loss or dizziness; Eyes — vision loss or double vision
• Face drooping; Arm (or leg) weakness or numbness, one side
• Speech — slurred, confused, or unable to speak
• Time — note the last known well time and call emergency services

Other findings: sudden severe headache (hemorrhage), dysphagia, dysarthria, ataxia, confusion, incontinence. Hemorrhagic stroke more often causes headache, vomiting, very high blood pressure, and rapid decline in LOC.

Assessment tools: NIH Stroke Scale (severity, change over time), GCS, bedside swallow screen before any oral intake, cardiac rhythm (atrial fibrillation).

The 2026 AHA/ASA acute ischemic stroke guideline expands reperfusion options; the key rules are below.

IV thrombolysis (ischemic stroke)

• Within 4.5 hours of last known well, for disabling deficits, regardless of NIHSS score, without advanced imaging.
• Either tenecteplase 0.25 mg/kg (maximum 25 mg) as a single IV bolus over about 5 seconds — half the myocardial infarction dose, so confirm the stroke-specific dose — or alteplase 0.9 mg/kg (maximum 90 mg; 10% as a bolus over 1 minute, the rest infused over 60 minutes).
• Nondisabling minor stroke is treated with antiplatelets rather than thrombolysis.
• Beyond 4.5 hours (up to about 9 hours, or when onset is unknown/on waking), thrombolysis may be reasonable if advanced imaging (MRI or perfusion) shows salvageable brain.
• Door-to-needle goal: 60 minutes or less (many centers target 45).
• Blood pressure must be below 185/110 mmHg before thrombolysis and kept below 180/105 mmHg for 24 hours after. Agents: IV labetalol, nicardipine, or clevidipine.
• Major contraindications: any intracranial hemorrhage on CT; recent (within 3 months) significant head trauma, ischemic stroke, or intracranial/spinal surgery; active internal bleeding; BP that cannot be lowered below 185/110; platelets below 100,000/mm³ (100 × 10⁹/L), INR above 1.7, or therapeutic anticoagulation (recent direct oral anticoagulant use is assessed per the stroke-center protocol); glucose below 50 mg/dL (2.8 mmol/L) with symptoms that resolve on correction.
• After thrombolysis: neuro checks and BP every 15 minutes for 2 hours, every 30 minutes for 6 hours, then hourly to 24 hours. No antiplatelets or anticoagulants for 24 hours and follow-up CT before starting them. Avoid invasive lines, NG tubes, and catheters when possible for 24 hours.
• Stop the alteplase infusion (if still running) and call the provider for sudden headache, nausea and vomiting, worsening neurologic status, or acute hypertension (suspect ICH). Watch for angioedema of the tongue and lips, especially with ACE inhibitor use.

Mechanical thrombectomy (endovascular thrombectomy, EVT)

• For anterior-circulation LVO within 6 hours with disabling deficits, and up to 24 hours when imaging shows salvageable tissue. Current guidance extends benefit to selected clients with large ischemic cores.
• Basilar artery occlusion within 24 hours with significant deficits (NIHSS ≥ 10) can also benefit.
• Thrombolysis, if eligible, should not delay transfer for thrombectomy.
• After EVT: groin or radial site, distal pulses, neuro checks. Targeting systolic BP below 140 mmHg for the first 72 hours after successful thrombectomy is harmful. Keep BP within the ordered range, commonly below 180/105. After IV thrombolysis in mild to moderate stroke, lowering below 140 mmHg also gives no benefit.

Blood pressure if no reperfusion therapy: permissive hypertension. BP is generally not lowered unless it exceeds 220/120 mmHg, and then by about 15% in the first 24 hours, because the brain's autoregulation depends on higher pressure to perfuse the penumbra.

Intracerebral hemorrhage (2022 AHA/ASA guideline)

• Mild–moderate ICH with systolic BP 150–220: lowering to a target of 140 mmHg (range 130–150) is reasonable; avoid dropping below 130. Smooth, sustained control matters.
• Reverse anticoagulation immediately: vitamin K antagonist → 4-factor prothrombin complex concentrate + IV vitamin K; dabigatran → idarucizumab; factor Xa inhibitors (apixaban, rivaroxaban) → 4-factor PCC (andexanet alfa was withdrawn from the US market in December 2025 because of thrombotic events).
• Manage ICP (Topic 64); surgery for selected cerebellar hemorrhage or hydrocephalus.

Antithrombotic therapy (ischemic stroke/TIA)

• Aspirin within 24–48 hours (after 24 hours if thrombolysis was given). Adverse effects: bleeding (gums, nose, GI), GI upset; avoid NSAIDs with it.
• Minor noncardioembolic stroke (NIHSS ≤ 5) or high-risk TIA: dual antiplatelet therapy (aspirin + clopidogrel) started within 72 hours for 21 days, then a single agent. Clopidogrel: bleeding; reduced effect with some CYP2C19 variants.
• Atrial fibrillation: long-term anticoagulation, generally a direct oral anticoagulant (apixaban, rivaroxaban, dabigatran) over warfarin (warfarin is still used with a mechanical heart valve or moderate–severe mitral stenosis); timing of start depends on stroke size. Monitor bleeding, kidney function; warfarin needs INR 2–3.
• High-intensity statin (atorvastatin): monitor liver enzymes, muscle pain.

Secondary prevention BP target: for most clients after stroke or TIA, below 130/80 mmHg (2021 AHA/ASA secondary prevention guideline). Older exam items using 140/90 are outdated.

Other: VTE prophylaxis (intermittent pneumatic compression; low-dose anticoagulant when safe), treat fever and hyperglycemia (avoid hypoglycemia; stroke-specific target about 140–180 mg/dL (7.8–10 mmol/L) — very tight IV insulin control is not recommended), carotid endarterectomy or stenting for significant symptomatic stenosis, early rehabilitation.

Listed in priority order.

1. Airway and aspiration prevention
   • Head of bed elevated, suction available, oxygen only if SpO₂ is below 94%.
   • Nothing by mouth until a swallow screen is passed.
   • Dysphagia: upright 90° for meals and 30 minutes after, thickened liquids and soft foods as ordered — thin liquids are the hardest to control, chin tuck, small bites, place food on the unaffected side, check the affected cheek for pocketed food, no straws unless cleared by speech therapy, oral care.
2. Neurologic monitoring
   • NIHSS/neuro checks per protocol; any deterioration after reperfusion therapy → recheck vital signs and neuro status and notify immediately (suspect hemorrhage or reocclusion).
   • Maintain BP within ordered limits; cardiac monitoring.
3. Safety and fall prevention
   • Call bell and belongings on the unaffected side; bed low and locked; nonslip footwear; scheduled toileting; bed/chair alarms as appropriate.
   • Do not keep all side rails up as a routine — clients may climb over them, and full rails count as a restraint; use them per policy and individual assessment.
   • Supervise impulsive (right-hemisphere) clients closely.
4. Positioning and contracture prevention
   • Support the affected arm on a pillow to prevent shoulder subluxation; never pull on the affected arm.
   • Position the affected arm with the elbow extended and palm up, fingers extended; prevent hip external rotation (trochanter roll) and foot drop.
   • Range-of-motion exercises; reposition at least every 2 hours.
5. Elimination
   • Stroke can cause urge incontinence or incomplete emptying — check post-void residual (bladder scanner); timed voiding; avoid indwelling catheters or remove them early. Bowel program for constipation.
6. Neglect and vision
   • Teach scanning (turning the head toward the affected side); approach from the affected side once the client can tolerate it to promote awareness. Early on, place key items on the unaffected side.
7. Communication
   • Aphasia: short simple sentences, one question at a time, yes/no questions, picture boards; do not rush or finish sentences.
8. ADLs and mood
   • Dressing: put on clothes on the affected side first; remove from the unaffected side first. Screen for post-stroke depression.

• Call emergency services immediately for any sudden weakness, facial droop, speech problem, vision loss, or severe headache — do not drive yourself or wait.
• Take antiplatelets or anticoagulants daily; report black stools, blood in urine, nosebleeds or gum bleeding that does not stop; use a soft toothbrush and electric razor; avoid NSAIDs unless approved.
• BP target for most survivors is below 130/80; check BP at home.
• Stop smoking, limit alcohol, eat a Mediterranean-style or low-sodium diet, be active as able, control diabetes and cholesterol.
• If the client has bladder retraining needs: explain that urine may remain in the bladder after voiding; follow timed voiding.
• Home safety: remove rugs, install grab bars, use assistive devices taught by therapy.

• CT without contrast first to rule out hemorrhage; check glucose (hypoglycemia mimics stroke).
• IV thrombolysis within 4.5 hours of last known well: tenecteplase 0.25 mg/kg (max 25 mg) or alteplase 0.9 mg/kg (max 90 mg).
• BP < 185/110 before and < 180/105 for 24 hours after thrombolysis; no antithrombotics for 24 hours.
• Thrombectomy for LVO up to 24 hours with imaging selection; after EVT, do not target SBP below 140 for 72 hours.
• No reperfusion: permissive hypertension up to 220/120.
• ICH: SBP target about 140; avoid < 130; reverse anticoagulants.
• Secondary prevention BP < 130/80.
• Swallow screen before anything by mouth; thicken liquids as ordered; food on the unaffected side.
• Right-hemisphere stroke = left neglect, impulsive; left-hemisphere stroke = aphasia.
• Affected arm: support, prevent subluxation; elbow extended, palm up.
• Aspirin → teach bleeding signs (gums, nose).