Hyperacute Essential Stroke Care Checklist
Christine Tunkl, Maria Giulia Mosconi and Götz Thomalla
This guideline is tailored for healthcare professionals in the in-hospital stroke patient care at both
essential and advanced stroke centers. The format of this guideline prioritizes actionable, evidence-
based recommendations. Hospitals aiming to implement this checklist must meet specific prerequisites,
including access to a CT scan, laboratory facilities, a well-equipped Emergency Department, an ICU,
the potential for acute thrombolytic therapy and endovascular treatment and a demonstrated proficiency
in stroke care. For healthcare facilities with a lower level of stroke care, immediate transfer of suspected
stroke patients to the nearest stroke-ready hospital is recommended.
Patient name: Patient Date of birth:
Date of presentation: Time of presentation:
A – General measures in hyperacute stroke care
- Suspected stroke / pre-notified stroke: Activate stroke code or inform stroke team if
possible / when available (neurologist, emergency physician, radiologist, nurse)
- Perform brain imaging without delay upon hospital arrival!
- Perform the following tasks in parallel by physicians and nurses according to a fixed
protocol:
Airway and breathing:
- Measure oxygen saturation: _________
- Provide supplemental oxygen to maintain saturation >94%.
- Tracheal intubation (with ICU team consultation if/when needed) is indicated for a
compromised airway (reduced level of consciousness? GCS ≤8?) or insufficient
ventilation (respiratory rate ≤ 6/minute?)
Circulation:
- Measure blood pressure: ________________________
- Correct hypotension and hypovolemia with crystalloid infusion.
- Treat hypertension when required by comorbidities.
In patients with hypertension >220/120mmHg, it’s reasonable to lower BP by 15%
during the first 24 hours after stroke onset.
Lower BP in patients who are eligible for thrombolysis or thrombectomy to
<185/110 before the procedure.
Lab diagnostics:
- Establish IV access (2 large bore cannulas)
- Check blood glucose: ___________
Treat hypoglycemia (<60mg/dl or 3.3mmol/L) with IV dextrose.
Treat hyperglycemia with a target of 140-180mg/dl (avoid hypoglycemia)
Neurological examination:
- Do a focused examination using a stroke severity scale (NIHSS): _______/42.
0 = Alert; keenly responsive.
1a. Level of 1 = Not alert; but arousable by minor stimulation
Consciousness 2 = Not alert; requires repeated stimulation to attend,
(LOC) Instructions: 3 = Responds only with reflex motor or autonomic effects or
totally unresponsive, flaccid, and areflexic.
0 = Answers both questions correctly.
1b. LOC Questions: 1 = Answers one question correctly.
2 = Answers neither question correctly.
0 = Performs both tasks correctly.
1c. LOC
1 = Performs one task correctly.
Commands:
2 = Performs neither task correctly.
0 = Normal.
2. Best Gaze: 1 = Partial gaze palsy.
2 = Forced deviation.
0 = No visual loss.
1 = Partial hemianopia.
3. Visual Fields:
2 = Complete hemianopia.
3 = Bilateral hemianopia.
0 = Normal symmetrical movements.
1 = Minor paralysis.
4. Facial Palsy:
2 = Partial paralysis.
3 = Complete paralysis of one or both sides.
0 = No drift.
5. Motor Arm: 1 = Drift.
5a. Left Arm 2 = Some effort against gravity.
5b. Right Arm 3 = No effort against gravity; limb falls.
4 = No movement.
0 = No drift.
6. Motor Leg: 1 = Drift.
6a. Left Leg 2 = Some effort against gravity.
6b. Right Leg 3 = No effort against gravity; limb falls.
4 = No movement.
0 = Absent.
7. Limb Ataxia: 1 = Present in one limb.
2 = Present in two limbs.
0 = Normal.
8. Sensory: 1 = Mild-to-moderate sensory loss.
2 = Severe to total sensory loss.
0 = No aphasia; normal.
1 = Mild-to-moderate aphasia.
9. Best Language:
2 = Severe aphasia.
3 = Mute, global aphasia.
0 = Normal.
10. Dysarthria: 1 = Mild-to-moderate dysarthria.
2 = Severe dysarthria.
0 = No abnormality.
11. Extinction and 1 = Visual, tactile, auditory, spatial, or personal inattention.
Inattention: 2 = Profound hemi-inattention or extinction to more than one
modality.
History - Obtain information about:
- Symptom onset / time last seen well: _____________________
- Current medication (if any): __________________________________________
Anticoagulants: __________ last time of drug intake: ______
- Absolute contraindications for thrombolytics: ________________________________
- Premorbid modified Rankin- Scale: _______/6.
Consider Doing:
- Delay nasogastric tube and bladder catheter, if the patient can be safely managed
without.
- Obtain other blood tests (CBC, electrolytes, creatinine, INR, pTT, troponin when
indicated) but do not delay the initiation of reperfusion therapy.
- Do ECG but do not delay initiation of reperfusion therapy.
DON'T DO:
- Blood pressure lowering in patients with ischaemic stroke and not receiving reperfusion
therapy unless blood pressure is very high (>220/120 mmHg) or blood pressure lowering
is indicated for other reasons.
- Systolic blood pressure should not be reduced more than 90 mmHg in acute ICH to
prevent kidney injury.
- Do not use antiepileptic drugs for primary prevention of seizures.
B - Imaging and recanalization for acute ischemic stroke
ACUTE IMAGING AND RECANALIZATION ALGORITHM
Time since onset 0 – 4.5h Time since onset 4.5-9h Unknown onset >4.5 h from >9 - < 24 hours
(known time window) (known time window) LSW
NO Thrombolyis!
Plain CT for IVT: Penumbral imaging for IVT Penumbral imaging OR FLAIR-
- Exclude bleeding CT and CT Perfusion OR DWI-Mismatch for IVT:
Thrombolysis (NINDS & MRI&MR-Perfusion MRI
ECASS 3) IVT is indicated if: – DWI pos/ FLAIR (neg) –mismatch
- Core <70ml (WAKE-UP) (MRI prefereable in minor
- Hypoperfused/Core ratio >1.2 strokes/ lacunas etc)
- mismatch volume >10ml
(=EXTEND criteria) CT and CT Perfusion or MRI Perfusion
- Core <70ml
- Hypoperfused/Core ratio >1.2
- mismatch volume >10ml
(=EXTEND criteria)
CT – Angio for MT: CT – Angio or MR-Angio: Detect Large Vessel Occlusion (LVO)?
- LVO?
Thrombectomy < 6 hours since onset: EVT
(MR-CLEAN, EXTEND- > 6 hours: Penumbral imaging / clinical-core mismatch for MT: CT-Perfusion/ MR-Perfusion
1A, ESCAPE, EVT is indicated if one of the following criteria sets is fulfilled:
REVASCAT, SWIFTPRIME)
DEFUSE-3 : 6 to 16 hours since time last known well:
2
SELECT-2 4
– Age ≤90 years and NIHSS ≥6: infarct core volume <70 - LVO and ASPECTS 3-5 or
ml and penumbra volume >15 ml and penumbra core>50ml
volume/core volume >1.8 ANGEL – ASPECTS 5
- LVO and ASPECTS 3-5 or
3
DAWN : 6 to 24 hours since time last known well: core 70 -100ml
– Age <80 years: infarct core ≤30 ml if NIHSS ≥10; infarct MR CLEAN-LATE 6 (CT and
core ≤ 51 ml if NIHSS ≥20. CTA only):
– Age ≥80 years: infarct core ≤20 ml and NIHSS ≥10 - LVO (incl M2)
- collateral flow >0% (grade 1-3)
C - Thrombolysis and Thrombectomy
Door - to - imaging time: ______ MIN (TARGET < 30 MIN!)
Door - to - needle time: ______ MIN (TARGET <30 min, SHOULD/MUST be <60 min!)
Door - to - groin time: ______ MIN (TARGET < 90 MIN!)
Administration:
Alteplase:
Total dose: ___kg*0.9mg/kg = _____ (max dose 90mg).
Bolus dose (10%) = ____mg (IV push over 1 minute): Starting time: ____________
infusion dose over 1 hours = _____mg
Tenecteplase:
Total dose: ___kg*0.25mg/kg = _____ Starting time: ____________
Blood pressure at thrombolysis:______________________ mm/Hg
Absolute Contraindications:
References:
2023: WSO Synthesis of global guidelines, ESO Guidelines, 2021: AHA Guidelines,
Angels Initiative Checklists, (1) N Engl J Med 2015; 372:1009-1018, (2) N Engl J Med
2018; 378:708-718, (3) N Engl J Med 2018; 378:11-21, (4) N Engl J Med 2023;
388:1259-1271, (5) N Engl J Med 2023; 388:1272-1283, (6) Lancet. 2023 Apr
22;401(10385):1371-1380, (7) N Engl J Med 2018; 379:611-622
Abbreviations:
IVT : intravenous thrombolysis
EVT: endovascular treatment / mechanical thrombectomy
