Stroke (Ischaemic)ICU / resuscitation

Sudden right weakness and slurred speech 90 min ago; BP 196/104; glucose 132 mg/dL; NIHSS 12

• Falling GCS or new headache/vomiting after lysis
• BP >185/110 before lysis
• Signs of large-vessel occlusion (gaze deviation, aphasia, neglect)
• Posterior circulation: vertigo, ataxia, diplopia, dysarthria

• Hypoglycaemia
• Seizure with Todd paresis
• Migraine with aura
• Intracerebral haemorrhage
• Subdural haematoma
• Brain tumour, functional disorder

• Admit: All acute stroke — to a stroke unit
• ICU: Post-thrombectomy or lysis monitoring where no stroke unit, GCS falling, malignant oedema, airway risk
• Intubate: GCS ≤8, loss of airway reflexes, malignant oedema
• Glucose: Keep 140–180 mg/dL; treat <60 mg/dL (intensive 80–130 not recommended)

• Time is brain: ~1.9 million neurons are lost every minute of a large-vessel stroke.
• Hypoglycaemia, seizure (Todd paresis), migraine and conversion disorder mimic stroke — check glucose first.
• Secondary prevention: BP <130/80, LDL <70 mg/dL, antiplatelet or DOAC (AF), smoking cessation, diabetes control.

• Give antiplatelets or anticoagulants for 24 h after thrombolysis
• Use tenecteplase 0.4 mg/kg (harm) — 0.25 mg/kg, max 25 mg
• Continue DAPT beyond 21–90 days for secondary prevention
• Drop SBP below 140 after successful thrombectomy (harmful)
• Feed by mouth before a swallow screen

• Anticoagulating before excluding haemorrhage
• Delaying thrombectomy transfer for lysis
• Long-term DAPT
• Missing AF (no cardiac monitoring)

Stroke unit for all; ICU for airway risk or malignant oedema. Rehabilitation and stroke clinic follow-up.