Stroke IQ is a demonstration application developed by John Peffer, MD.
This tool is intended for demonstration and educational purposes only and does not provide medical advice or replace clinical judgment.
Clinical pathways and recommendations are based on the 2026 AHA/ASA Guidelines for the Early Management of Acute Ischemic Stroke, but may not reflect all patient-specific factors or institutional protocols.
Always follow local policies and use independent clinical judgment when making treatment decisions.
Table 8 — 2026 AHA/ASA Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Prabhakaran S et al. Stroke. 2026;57.
⚡ Stroke IQ
Acute Ischemic Stroke Assessment Tools
Demo Version
Brought to you by John Peffer, MD
Based on 2026 AHA/ASA Guideline for the Early Management of Patients With Acute Ischemic Stroke
Prabhakaran S et al. Stroke. 2026;57. doi:10.1161/STR.0000000000000513
Contraindication categories per Table 8 color-coded risk gradient:
■ Pinkish Red = Absolute ·
■ Peach = Relative ·
■ Light Teal = Benefit > Risk
⚠️ Clinical Decision Support Tool • This tool assists with TNK candidacy assessment but does not replace clinical judgment. Always consider individual patient factors and consult institutional protocols.
⏱
Would you like to start a stopwatch?
Counts up from now — appears alongside the IVT Time Remaining timer
1
Clinical Diagnosis & Deficit Severity
Clinical diagnosis for ischemic stroke
Are the patient's symptoms functionally disabling? Would they prevent: · basic activities of daily living (e.g., BATHE: Bathing, Ambulating, Toileting, Hygiene, Eating) · or returning to normal work/roles?
Determine in consultation with patient and family. Primarily applies to NIHSS 0–5; higher scores generally disabling. IVT eligibility requires disabling deficits regardless of NIHSS score (COR 1, A).
Cannot perform ADLs → Disabling
Can perform ADLs → Non-disabling
⚠️ Non-Disabling Deficit — IVT Not Recommended
Per 2026 AHA/ASA (COR 3, B-NR), IVT has not shown superiority over DAPT for non-disabling strokes within 4.5 hours. Dual antiplatelet therapy (DAPT) is the preferred treatment.
Onset Type:📍 Known Onset / LKW — standard 4.5h window; use 24h or 12h format. For LKW 4.5–9h, enter known LKW time and the app routes to extended-window perfusion pathway automatically. ❓ Unknown Onset — onset unknown or patient awoke with symptoms (wake-up stroke); if within 4.5h of symptom recognition: MRI DWI-FLAIR mismatch pathway; beyond 4.5h: perfusion imaging (CTP or MR Perfusion). EVT remains an option up to 24h for eligible LVO patients.
❓ Unknown Onset Pathway
Stroke onset is unknown and not sleep-related. IVT eligibility requires advanced imaging. If symptoms were recognized within 4.5h, the guideline-primary pathway is MRI DWI-FLAIR mismatch. If beyond 4.5h from recognition, perfusion imaging may support eligibility with stroke neurology guidance.
Time symptoms were first recognized / discovered (optional — gates imaging pathway)
Within 4.5h of recognition → MRI DWI-FLAIR pathway. Beyond 4.5h → perfusion pathway.
:
⚕️ Confirm imaging availability in the Inclusion Criteria section. Imaging results entered at end of Full Stroke Pathway, before TNK dosing.
3
Pre-Treatment Requirements
Both must be confirmed before IVT administration.
Blood glucose checked
Severe hypoglycemia (<50 mg/dL) or hyperglycemia (>400 mg/dL) corrected. IVT eligible if disabling deficits persist after correction.
BP manageable to <185/110 mmHg
SBP <185 mmHg and DBP <110 mmHg achieved or achievable before IVT initiation.
4
NIH Stroke Scale
NIHSS total: 0 (No stroke symptoms)
:
5
Absolute Contraindications
Tap anything present in this patient. Leave untouched if absent.
6
Relative Contraindications
Tap anything present. Relative contraindications require individualized risk-benefit discussion.
7
IVT Benefit Generally > Risk
These do not preclude IVT. Tap to acknowledge each that applies.
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Imaging-Based Eligibility
✅
TNK Candidate
Discussed risks, benefits, and alternatives to TNK?
Patient / surrogate decision
💉
TNK Dose Calculator
:
For Providers Only
Time spent in critical care of this patient
Used for physician documentation and billing support
minutes
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LVO Management
Applies independently of standard TNK eligibility
Large vessel occlusion (LVO) identified?
Based on CTA, MR angiography, or clinical suspicion.
Large Vessel Occlusion Detected
Endovascular thrombectomy is the standard reperfusion therapy for eligible LVO patients. Proceed without delay.
Is EVT available at this facility / for this patient?
✓ Proceed to EVT Immediately
Do not delay definitive reperfusion while observing for clinical response. Activate the neurointerventional team now.
⚠️ EVT Unavailable — evaluating whether limited-evidence IVT pathway applies based on timing and imaging.
TNK (Tenecteplase) Dosing — 2026 AHA/ASA
• 0.25 mg/kg IV bolus over 5 seconds
• Maximum dose: 25 mg (patients ≥100 kg)
• Reconstituted concentration: 5 mg/mL (50 mg vial / 10 mL)
• Do not administer if BP not manageable to <185/110 mmHg
• If LVO present: proceed to EVT without delay
Are the patient's symptoms functionally disabling? Would they prevent: · basic activities of daily living (e.g., BATHE: Bathing, Ambulating, Toileting, Hygiene, Eating) · or returning to normal work/roles?
Determine in consultation with patient and family. Primarily applies to NIHSS 0–5; higher scores generally disabling. IVT eligibility requires disabling deficits regardless of NIHSS score (COR 1, A).
Cannot perform ADLs → Disabling
Can perform ADLs → Non-disabling
⚠️ Non-Disabling Deficit — IVT Not Recommended
Per 2026 AHA/ASA (COR 3, B-NR), IVT has not shown superiority over DAPT for non-disabling strokes within 4.5 hours. Dual antiplatelet therapy (DAPT) is the preferred treatment.
Stroke onset unknown and not sleep-related. IVT eligibility requires advanced imaging. Confirm availability below — imaging results will be reviewed at end of Full Stroke Pathway.
Time symptoms were first recognized (optional — gates imaging pathway)
<3h and 3–4.5h: NINDS (1995), ECASS III (2008), IST-3 (2012). 4.5–9h: EXTEND (2019), ECASS4-EXTEND, EPITHET — Campbell et al, Lancet 2019 meta-analysis.
Good outcome (benefit)Symptomatic ICH (harm)No event
⚠️ Imaging-selected pathway only. These numbers apply when CT perfusion or MRI shows a perfusion-diffusion mismatch (salvageable penumbra). Patients without mismatch did not benefit in trial data. Source: EXTEND (2019), ECASS4-EXTEND, EPITHET — Campbell et al, Lancet 2019.
Consider head-of-bed flat (0°) if tolerated while awaiting reperfusion
✓
Maintain oxygenation — consider low-flow supplemental O₂ if appropriate
⚠️ Evidence for positioning and oxygen strategies remains limited.
Not all patients tolerate supine positioning (e.g., aspiration risk, pulmonary edema). Use clinical judgment.
CHECKLIST PROGRESS0 / 7 complete
✓
🫁Oxygenation Monitoring
Monitor SpO₂ continuously. Provide supplemental O₂ to maintain SpO₂ >94%.
⚠️ Routine O₂ in non-hypoxic patients not recommended (COR 3, B-R)
✓
🌡️Temperature Management
Treat hyperthermia. Target normothermia using nurse-initiated fever protocols (temp >37.5°C). Identify and treat infectious sources.
⚠️ Induced hypothermia in normothermic patients not recommended (COR 3, B-R)
✓
🩺Blood Pressure — Post-IVT
Maintain BP <180/105 mmHg for at least the first 24 hours after IVT (COR 1, B-R).
⛔ Do NOT aggressively lower to <140 mmHg
Intensive SBP reduction to <140 mmHg post-IVT is not beneficial and may cause harm (COR 3, B-R)
✓
🩺Blood Pressure — Permissive HTN
If BP <220/120 mmHg and no comorbid indication (ACS, aortic dissection, acute HF, pre-eclampsia): do NOT routinely lower BP in the first 48–72 hours — no benefit demonstrated (COR 3: No Benefit, A).
Treat hypoglycemia (<60 mg/dL) immediately (COR 1, C-LD).
For persistent hyperglycemia: target 140–180 mg/dL with close monitoring (COR 2a, C-LD).
⚠️ Avoid intensive insulin targeting 80–130 mg/dL — no benefit, increased hypoglycemia risk (COR 3, A)
✓
👄Swallow Screen
Perform bedside swallow screen before any oral fluid or food intake (COR 1, C-EO). If failed or unable to participate, formal endoscopic swallowing evaluation is reasonable (COR 2a, B-NR).
Do not place an indwelling bladder catheter routinely — associated with catheter-related UTIs and independently predicts poor 3-month outcome (COR 3: Harm, C-LD). If required, remove as early as clinically feasible.
Prabhakaran S et al. Stroke. 2026;57. doi:10.1161/STR.0000000000000513 · §4.1, 4.3, 4.4, 4.5, 5.2, 5.4, 5.6
⚠️ Clinical Emergency Guidance · Recognize early. Stop infusion immediately if still running. Engage appropriate consultants. All dosing should be confirmed against institutional protocols.
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Symptomatic ICH
Most feared complication · Incidence ~5%
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Recognition
New or worsening neurological deficit · ↓ level of consciousness · acute headache · nausea/vomiting · elevated BP · occurs within 24–36h of IVT (most within 12h)
Management
✓
Stop TNK infusion immediately if still infusing. Call stroke neurology / neurosurgery stat.
✓
Emergent labs: CBC · PT (INR) · aPTT · fibrinogen level · type and cross-match
✓
STAT non-contrast CT head. Confirm hemorrhage location and extent.
✓
Reverse fibrinolysis — fibrinogen replacement: Cryoprecipitate 10 units IV (each unit ↑ fibrinogen ~10 mg/dL). Goal fibrinogen >150 mg/dL. Check level; repeat if needed.
✓
Antifibrinolytic (give with cryoprecipitate): Tranexamic acid 1 g IV over 10 min ORAminocaproic acid 4–5 g IV over 1h, then 1 g/hr × 8h
✓
Platelets if count <100,000/mm³: 1 apheresis unit IV
✓
BP control: Target SBP <140 mmHg for hemorrhagic transformation. Use Labetalol IV or Nicardipine IV — see HTN card.
✓
Neurosurgery consult for hematoma evacuation if clinically indicated. ICP monitoring if herniation risk.
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Orolingual Angioedema
ACE inhibitor use ↑ risk · Airway emergency
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Recognition
Tongue, lip, or oropharyngeal swelling · typically contralateral to ischemic hemisphere · onset 30–120 min after IVT · may progress to complete airway obstruction · high-risk if on ACE inhibitor
Management
✓
Stop TNK infusion immediately. Call anesthesia / ENT early — do not wait for severe swelling.
✓
Airway assessment: If stridor, drooling, or inability to swallow — immediate intubation. Early fiberoptic nasal intubation preferred if time allows.
✓
Epinephrine (moderate–severe): Epi 0.3–0.5 mg IM (1:1000) into lateral thigh. Repeat q5–15 min PRN. OREpi 0.1 mg IV (1:10,000) if hemodynamically unstable.
✓
Icatibant (if available — bradykinin B2 receptor antagonist): 30 mg (3 mL) SC into abdominal area. May repeat 30 mg q6h · max 3 injections/24h. Also consider plasma-derived C1 esterase inhibitor 20 IU/kg IV. Particularly useful in ACE inhibitor-related angioedema.
✓
Diphenhydramine 50 mg IV (H1 blocker) Famotidine 20 mg IV (H2 blocker) Methylprednisolone 125 mg IVORHydrocortisone 200 mg IV
✓
Discontinue ACE inhibitor immediately. Do not restart.
✓
Monitor closely for 12–24h even if initial swelling appears mild — can progress rapidly.
Stop TNK infusion immediately. Direct pressure on all accessible bleeding sites.
✓
Two large-bore IVs. Type & crossmatch. Stat CBC, fibrinogen, PT/PTT. Activate massive transfusion protocol if hemodynamically unstable.
✓
Primary reversal — PCC and cryoprecipitate: PCC 25–50 units/kg IV — administer promptly Cryoprecipitate 10 units IV — correct fibrinogen deficit, goal >150 mg/dL Note: Antifibrinolytics (TXA or aminocaproic acid) may have some benefit if blood products are contraindicated or cryoprecipitate is not promptly available (AHA/ASA AIS 2026 Table 5).
✓
Transfusion as needed: pRBC for hemodynamic instability or Hgb <7 FFP 4 units if coagulopathy Platelets if <50,000/mm³
✓
GI / surgery / interventional radiology consult for source localization and definitive hemorrhage control.
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Hypertensive Emergency
SBP >180 or DBP >105 mmHg post-IVT
▾
Target
Maintain SBP <180 / DBP <105 mmHg for first 24h post-IVT (2026 AHA/ASA COR 1, B-R). ⛔ Do NOT lower SBP aggressively to <140 mmHg — no benefit, potential harm (COR 3, B-R).
Management
✓
Labetalol 10–20 mg IV over 1–2 min. Repeat or double q10 min · Max cumulative 300 mg. Avoid if bradycardia, acute HF, or bronchospasm.
✓
Nicardipine 5 mg/hr IV infusion — titrate by 2.5 mg/hr q5–15 min · Max 15 mg/hr. Good choice if labetalol contraindicated.
✓
Clevidipine 1–2 mg/hr IV — titrate by doubling q90 sec · Max 21 mg/hr. Rapid calcium channel blocker; preferred if tight titration needed.
✓
If SBP >230 or DBP >140:Sodium nitroprusside 0.5–1 mcg/kg/min IV Use cautiously — may raise ICP.
✓
Recheck BP q5–15 min during active titration. Continuous BP monitoring for first 24h post-IVT.
Prabhakaran S et al. Stroke. 2026;57. doi:10.1161/STR.0000000000000513 · §4.3 · Institutional protocols should be followed for all dosing.