Stroke Code Activation
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Direct answer
A stroke code compresses the interval between a blocked cerebral artery and the drug that opens it: recognition by FAST (Face droop, Arm weakness, Speech difficulty, Time), a door-to-CT target of about 25 minutes, a glucose to exclude the great mimic, and intravenous alteplase at 0.9 mg/kg — maximum 90 mg, ten per cent as a bolus, the rest over an hour — within 4.5 hours of a clearly defined onset. Blood pressure must sit under 185/110 before and under 180/105 after thrombolysis, and large-vessel occlusions route to mechanical thrombectomy, in selected patients out to 24 hours by imaging criteria. Every minute of delay costs cortex — roughly 1.9 million neurons per minute in an untreated large-vessel occlusion, the number that justifies the entire pathway.
What you must remember
- FAST as the door test: facial droop, arm drift, speech abnormality — any one with sudden onset activates the pathway; onset time is hunted from witnesses as last-seen-well.
- Time targets: door-to-CT about 20-25 minutes, door-to-needle within 60 minutes; the onset-to-needle ceiling is 4.5 hours.
- Alteplase arithmetic: 0.9 mg/kg to a maximum of 90 mg; 10 per cent intravenously over one minute, the remaining 90 per cent over 60 minutes.
- Blood pressure gates: below 185/110 before lytic, managed with labetalol or nicardipine-type agents; below 180/105 for the 24 hours after.
- Mimic exclusion at the bedside: capillary glucose on arrival — hypoglycaemia reproduces focal deficits and reverses in minutes; seizure and migraine also mimic.
- Absolute contraindication anchors: haemorrhage on CT, recent surgery or head trauma, active bleeding, severe coagulopathy — the checklist is read aloud before consent.
- Thrombectomy reality: CT angiography identifies large-vessel occlusion; mechanical clot retrieval is standard within 6 hours and, in selected patients with favourable perfusion imaging, up to 24 hours from last-seen-well.
- Post-lytic discipline: no antiplatelets or anticoagulants for 24 hours, pressure surveillance, and a swift re-scan for deterioration — which may reveal haemorrhage needing neurosurgery.
Running the clock on a 6:40 am arrival
A 67-year-old arrives by 108 ambulance; her husband says she was normal at 6:10 and found at 6:30 with a slack face and a lifeless right arm. The pre-alert has rung the stroke pager, the CT slot is held, the radiographer waiting. Triage takes seconds — FAST positive, onset 6:10 — and the trolley goes straight to the scanner with the glucose meter alongside: 6.2 mmol/L, mimic excluded. The non-contrast CT shows no haemorrhage and no established infarct; door-to-CT is 19 minutes. Two cannulae are in, consent has been taken with the husband present, and the pressure of 194/96 is brought to 178/92 with labetalol before any drug is drawn — the 185/110 gate is absolute. Alteplase is computed at 68 kg: 61 mg total, 6 mg bolus over one minute, then 55 mg over the hour. During the infusion she moves to the stroke unit with nothing else through the line, neurological score rechecked hourly. Her CT angiogram had shown a proximal middle cerebral artery clot, so the thrombectomy team at the hub is notified and accepts — the ambulance leaves with the infusion running, a nurse escorting, the angiography suite held: door to acceptance, 74 minutes.
Where students slip
Candidates reach for the drug before the gates: a stem with pressure 200/115 expects labetalol first — "start alteplase now" has failed the check real pathways enforce. The second slip is the clock — onset means last-seen-well, so a wake-up stroke found at 7 am may already be outside the 4.5-hour window; a trap built into many vignettes. The third is the mimic: sweating and tremor point to hypoglycaemia, a deficit marching across fingers to migraine aura — the bedside glucose is the cheapest discriminator in the building. Indian viva examiners add the systems layer — which centres hold thrombolysis and thrombectomy capability, how district stroke pathways use telephonic CT reporting, and why last-seen-well belongs on the transfer sheet: in a hub-and-spoke reality the ECCT staff often are the pathway.
Frequently asked questions
What is the standard dose and window for alteplase in ischaemic stroke?
0.9 mg/kg intravenously (maximum 90 mg), 10 per cent as a one-minute bolus and the rest over an hour, within 4.5 hours of a clearly established onset.
What blood pressure must be reached before thrombolysis?
Below 185/110 mmHg before the drug, typically with intravenous labetalol, and below 180/105 maintained for at least 24 hours afterwards.
Why is a bedside glucose done before activating the drug?
Hypoglycaemia produces focal deficits that fully reverse with glucose — every stroke pathway tests it before committing to a thrombolytic with bleeding risk.
Up to what time can mechanical thrombectomy be offered?
Routinely within 6 hours of onset, and in selected patients with favourable perfusion imaging, up to 24 hours from last-seen-well for large-vessel occlusion.
What defines onset time in a wake-up stroke?
The last time the patient was seen well, not the time symptoms were noticed — the anchor for every window decision and the fact most often misstated in exams.