A stroke occurs when there is a sudden disruption in the continuous flow of blood to the brain, resulting in the loss of neurological function. This disruption can be caused in two main ways either due to a blockage in the blood vessels, causing an ischemic stroke (the most common type), or from bleeding within the brain, leading to a hemorrhagic stroke (often more severe and deadly). Strokes usually strike with little or without warning, and their effects can be life-altering or even fatal.
Stroke is most commonly associated with older adults but the recent trends show a concerning rise in stroke cases among younger individuals under the age of 49. According to the National Institute of Neurological Disorders and Stroke (NINDS), nearly 75% of all strokes still occur in those over 65, but the risk of stroke doubles with each decade after age 55 highlighting the importance of stroke awareness across all age groups.
Because time is critical when dealing with a stroke, healthcare providers follow the ACLS Suspected Stroke Algorithm — a structured, step-by-step process designed to rapidly recognize and treat stroke symptoms. This process involves identifying early stroke warning signs, calling for emergency medical assistance, noting the time when symptoms first appeared, performing a rapid stroke assessment, monitoring vital functions like Airway, Breathing, and Circulation (ABCs), transporting the patient to the nearest hospital, conducting brain imaging tests, and initiating treatment.
Every action within this algorithm revolves around one vital principle: speed saves the brain. In stroke care, every minute matters because, as experts often say, “Time is brain.” The faster the treatment begins, the greater the chances of limiting brain damage and improving recovery outcomes.
Strokes are classified into two main types based on the cause of disrupted blood flow to the brain i.e. Ischemic Stroke and Hemorrhagic Stroke. Each type has its own subtypes, causes, and treatments, which are specialized according to the specific mechanism of the stroke.
An Ischemic Stroke occurs when a blood vessel supplying the brain becomes blocked commonly by a blood clot or other obstruction. This blockage reduces blood flow and deprives brain tissue of oxygen and nutrients, leading to cell damage or death.
Causes of Ischemic Stroke:
Types of Ischemic Stroke:
Treatment for Ischemic Stroke:
Percentage:
Ischemic strokes account for about 87% of all stroke cases. (Source: American Stroke Association)
A hemorrhagic stroke happens when a weakened blood vessel in the brain bursts, and causes bleeding (hemorrhage) either inside the brain or in the surrounding areas. This bleeding increases pressure on the brain, which can damage brain cells and tissues.
Causes of Hemorrhagic Stroke:
Types of Hemorrhagic Stroke:
Treatment for Hemorrhagic Stroke:
Percentage:
Hemorrhagic strokes make up about 13% of stroke cases.
Recognizing the signs of a stroke quickly can save a life. A simple and effective way to remember the common stroke symptoms is through the acronym BE FAST. Each letter highlights a key warning sign to watch for:
Identifying these symptoms early and seeking immediate medical attention greatly improves the chances of recovery and reduces the risk of long-term disability.
Note: The BE FAST model was developed by Intermountain Healthcare as an enhanced version of the original FAST model from the American Stroke Association. It is used with permission from Intermountain Healthcare. Copyright 2011, Intermountain Health Care.
The NIH Stroke Scale is used to assess the severity of a stroke. While the scale itself is a detailed scoring system based on neurological function (with scores ranging from 0 to 42), the results are often grouped into five general levels of stroke severity to help guide treatment and diagnosis:
|
NIHSS Score Range |
Stroke Severity |
Description |
| 0 |
No Stroke Symptoms |
Normal neurological function. |
|
1–4 |
Minor Stroke |
Mild symptoms; often minimal impairment. |
|
5–15 |
Moderate Stroke |
Noticeable neurological deficits but potentially recoverable. |
|
16–20 |
Moderate to Severe Stroke |
Significant impairment; higher risk of complications. |
|
21–42 |
Severe Stroke |
Extensive neurological deficits: poor diagnosis if not promptly treated. |
Each level helps clinicians make decisions about interventions such as thrombolytic therapy, mechanical thrombectomy, or rehabilitation planning.
Stroke treatment follows an evidence-based, rapid-response protocol guided by Advanced Cardiovascular Life Support (ACLS) algorithms. The primary goals are early recognition, immediate evaluation, rapid imaging, and prompt treatment to minimize brain damage and improve patient outcomes.
Key Treatment Pathways:
Ischemic Stroke: Focus on the timely administration of intravenous (IV) thrombolysis (tPA) or mechanical thrombectomy to restore blood flow.
Hemorrhagic Stroke: Prioritize controlling bleeding, reducing intracranial pressure, and surgical interventions if necessary.
Rehabilitation & Prevention: Early rehabilitation and prevention of complications are essential to support recovery and reduce long-term disability.
Early recognition of stroke symptoms is critical for initiating timely care. Be alert to signs such as sudden numbness or weakness in the face, arm, or leg, particularly on one side of the body, difficulty speaking or understanding speech and sudden loss of coordination, balance issues, dizziness, or coordination.
If a stroke is suspected, a “stroke alert” or “code stroke” is initiated triggering the response of a specialized stroke team. Generally, such a team includes neurologists, emergency physicians, and radiologists, to mobilize for urgent assessment and treatment.
The patient’s vital signs are evaluated, and a detailed medical history is collected, including the exact time of symptom onset. This onset time is crucial for determining eligibility for time-sensitive treatments such as thrombolysis.
4. Neurological Test
A structured neurological evaluation is performed, normally using the NIH Stroke Scale (NIHSS). This exam assesses motor function, speech, sensory response, and level of consciousness, helping to quantify the severity of stroke symptoms.
Within 20 minutes of hospital arrival, a non-contrast CT (Computed Tomography ) scan or MRI (Magnetic resonance imaging) is performed on patients. Imaging differentiates between ischemic and hemorrhagic stroke, guiding the next steps in treatment.
Blood tests like a complete blood count (CBC), coagulation studies, and blood glucose levels are performed to help identify other possible causes of stroke-like symptoms and to determine whether certain treatments are appropriate.
If an ischemic stroke is confirmed and the patient meets the criteria, thrombolytic therapy using a drug such as tissue plasminogen activator (tPA) is the only medication approved by the U.S. Food and Drug Administration (FDA) in 1996. This FDA-approved therapy dissolves clots, restoring blood flow to affected brain tissue.
Blood pressure is closely monitored and controlled to maintain optimal levels, ensuring sufficient blood flow to the brain while minimizing the risk of hemorrhagic transformation (bleeding in the brain) following thrombolytic therapy.
Once the patient is stabilized, further assessment is carried out to pinpoint the cause of the acute stroke and guide strategies for preventing future strokes. This involves vascular imaging, such as CT angiography or MR angiography, as well as additional tests to evaluate heart function and rhythm.
Recovery doesn’t end at discharge. Multidisciplinary rehabilitation including physical therapy, occupational therapy, and speech-language pathology supports functional recovery. Ongoing follow-up addresses risk factor control, medication adherence, and psychosocial support.
Below is a breakdown of the key time frames healthcare providers aim to hit during acute stroke care. Recognizing and acting within critical time frames can significantly impact patient recovery and survival.
|
Step |
Description |
Time Goals |
| Initial Assessment |
Rapid triage and evaluation upon patient arrival to identify stroke symptoms and severity. |
10 minutes |
|
Neurological Assessment |
Detailed neurological exam using tools like the NIH Stroke Scale (NIHSS) to determine the extent of neurological deficits. |
25 minutes |
|
CT Scan Acquisition |
Non-contrast head CT or MRI to rule out hemorrhage and confirm ischemic stroke. |
Within 25 minutes |
|
CT Scan Interpretation |
Imaging reviewed by radiologists or stroke specialists to guide treatment decisions. |
Within 45 minutes |
|
Fibrinolytic Therapy |
Initiation of IV (intravenous) thrombolytics (e.g., alteplase) if the patient meets criteria “door-to-needle” goal is under 60 minutes. |
Within 60 minutes |
|
Endovascular Therapy |
Mechanical thrombectomy is considered for eligible patients with large vessel occlusion. |
Within 6 hours |
|
Admission to Monitored Bed |
Transfer to the stroke unit, ICU (Intensive Care Unit), or monitored setting for continuous observation and further management. |
Within 3 hours |
|
Door-to-Needle Time (DTN) |
The time from hospital arrival to IV (intravenous) thrombolysis goal: ≤60 minutes for optimal outcomes. |
|
| Golden Hour |
The first 60 minutes after stroke onset, during which intervention has the highest potential to minimize brain damage and improve outcomes. |
Effective post-stroke care starts as soon as a patient presents with symptoms and continues through recovery and discharge. Timely evaluation and coordinated interventions are key to preventing recurrence and promoting recovery.
Conduct a comprehensive stroke assessment, including laboratory tests, ECG (Electrocardiogram), and vascular imaging, to identify the cause of the stroke and guide strategies for secondary prevention.
Begin appropriate therapies to prevent stroke recurrence, such as antiplatelets, anticoagulants, statins, and blood pressure management.
Evaluate for dysphagia to minimize the risk of aspiration, and initiate patient education on lifestyle modifications to address and reduce stroke risk factors.
Early rehabilitation after a stroke should begin as early as possible to promote recovery and prevent complications. A structured approach ensures optimal functional outcomes and smooth transition from hospital to home care.
Conduct an early rehabilitation assessment involving physical therapy, occupational therapy, and speech therapy, and initiate patient mobilization.
Deliver daily rehabilitation therapies and assess the patient’s ongoing rehabilitation needs to plan for appropriate services at discharge.
Provide training and education to caregivers to prepare them for supporting the patient’s post-stroke care and recovery needs.
Effective discharge planning is essential to ensure a smooth transition from hospital to the next phase of care. It helps reduce readmissions and supports patients in achieving the best possible recovery outcomes.
Assess and determine the most suitable discharge destination, such as returning home or transitioning to a rehabilitation facility, based on the patient’s condition and support needs.
Initiate coordination of home health services adjusted to the patient’s specific needs to ensure continuity of care after discharge.
Complete the transfer process within 7 days and ensure clear communication with the receiving facility regarding the patient’s care requirements.
Ensure that all necessary equipment, medications, and outpatient therapy plans are prepared and in place to support a safe discharge.
The ACLS Suspected Stroke Algorithm stresses fast recognition and action to improve results. Early use of tools like the NIHSS, quick EMS activation calling 911 or your local emergency number without delay, and transport to a stroke-ready facility are vital. At the hospital, rapid assessment, imaging, and stroke type identification guide treatment such as thrombolytics for ischemic stroke. “Time is brain” every second counts.
Yes, blood pressure management is very important in stroke care. High blood pressure can make a stroke worse, and controlling it helps protect the brain and prevent more strokes. Keeping blood pressure at a safe level helps the patient heal and stay healthier.
If a patient has a stroke and cardiac arrest, doctors first focus on restarting the heart with CPR and defibrillation. Stroke treatment comes after the patient is stable.
The action not part of the acute stroke is seizure prophylaxis, which is generally not administered routinely unless they are specific.
