Acute Ischemic Stroke — Reperfusion Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Emergency assessment · non-contrast CT
   Non-contrast CT result? (Activate the stroke code on suspicion: secure airway/oxygen, check glucose, NIHSS, urgent non-contrast CT (CTA for large-vessel occlusion / LVO if indicated), blood pressure, and record the last-known-well (LKW) time.)
   • No hemorrhage (presumed ischemic) → Time-window assessment (LKW)
   • Intracranial hemorrhage seen → Intracranial hemorrhage
2. [End] Intracranial hemorrhage
   CT shows hemorrhage, not ischemic stroke: move to the intracerebral / subarachnoid hemorrhage pathway — blood-pressure control, reverse coagulopathy, neurosurgical assessment; thrombolysis and thrombectomy are contraindicated.
3. [Decision] Time-window assessment (LKW)
   How long since last known well? (For wake-up stroke or unknown onset, DWI-FLAIR mismatch or CT/MR perfusion core–penumbra mismatch can help select reperfusion.)
   • ≤4.5 h → IV thrombolysis + assess thrombectomy
   • >4.5–24 h (or wake-up/unknown) → Extended window · thrombectomy?
4. [End] IV thrombolysis + assess thrombectomy
   Within 4.5 h, no contraindications, disabling deficit → thrombolyse as fast as possible: alteplase 0.9 mg/kg (max 90 mg) or tenecteplase 0.25 mg/kg (max 25 mg), both recommended as equivalent, door-to-needle target ≤60 min; BP must be <185/110 mmHg before thrombolysis. Also assess anterior-circulation LVO with CTA; if LVO, perform mechanical thrombectomy (may bridge with thrombolysis). (Note: Disabling deficits should be thrombolysed regardless of NIHSS; benefit of treating non-disabling deficits within the 4.5 h window is unproven.)
5. [Decision] Extended window · thrombectomy?
   Anterior-circulation LVO with imaging mismatch? (Requires CT/MR perfusion or DWI to assess the ischemic core and salvageable tissue (DAWN/DEFUSE-3 criteria).)
   • Yes (LVO + mismatch criteria met) → Mechanical thrombectomy
   • No (no LVO or mismatch negative) → Intensive medical management
6. [End] Mechanical thrombectomy
   6–16 h meeting DAWN/DEFUSE-3 → mechanical thrombectomy (Class I); 16–24 h meeting DAWN → thrombectomy (IIa). Transfer to a center with neurointervention as fast as possible — quicker assessment and recanalization is better. Selected perfusion/MRI-selected patients at 4.5–24 h may be considered for IV thrombolysis. (Note: Time is brain: shortening door-to-puncture / recanalization time directly improves outcome.)
7. [End] Intensive medical management
   Not eligible for reperfusion (out of window / no LVO / mismatch negative): antiplatelet (aspirin; after 24 h if thrombolysed), permissive hypertension avoiding over-aggressive lowering, glucose and temperature control, swallow assessment to prevent aspiration, work up the cause (AF / large-artery / small-vessel) and start secondary prevention, early rehabilitation.

Source guidelines & references

• 2026 AHA/ASA Guideline for the early management of acute ischemic stroke. Stroke 2026 · source ↗
• DAWN (NEJM 2018) / DEFUSE-3 (NEJM 2018) extended-window thrombectomy trials

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways