ENLS · Cerebrovascular Emergencies · Neuro Series 1
Acute Stroke Initial Assessment
Clinical suspicion → Prehospital → ED assessment → Brain imaging → Branch to AIS / ICH / SAH
Out of Hospital
- Acute onset focal neurologic symptoms
- 911 / EMS services alerted
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- ABCs
- Stroke screening tool
- Time last known normal
- Medication list — especially anticoagulants: warfarin, heparin (dialysis), LMWH (enoxaparin, dalteparin), dabigatran, apixaban, rivaroxaban — and when last taken
- Consider triage to stroke centre
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- ABCs
- Focused neurologic exam within 5 minutes: GCS, NIHSS
- History: medications, atrial fibrillation
- Labs: CBC with platelets, PT/PTT, INR, capillary glucose, EKG, beta-HCG (women)
- IV access
- O₂ to maintain sat >94% — hyperoxia may be detrimental, no high-flow O₂ unless needed
- Activate stroke code system (if available)
- Stroke MD/team to evaluate within 5 minutes
- Determine NIHSS score
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- CT or MRI — CT is usually faster
- Consider Stroke CT: non-contrast head CT + CTA neck and brain + CT perfusion
- Consider MRI: MRA head and neck + DWI + MR perfusion
- Note: tPA inclusion/exclusion decisions are based on non-contrast CT head alone
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✅ NO HAEMORRHAGE — Ischaemic Stroke / Normal CT
🫀
CT/MRI: normal or ischaemic infarct → proceed to Ischaemic Stroke protocol
💥 SAH — Blood in Subarachnoid Space
💥
Predominant blood in subarachnoid space
- Head trauma present → consider Traumatic Brain Injury protocol
- No head trauma → likely ruptured cerebral aneurysm → SAH protocol
🩸 ICH — Blood in Brain Parenchyma
🩸
Most blood within brain parenchyma (including ventricle)
- Head trauma present → consider Traumatic Brain Injury protocol
- No head trauma → ICH protocol
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Checklist
- ☐ Establish time of onset (time last seen normal)
- ☐ Vital Signs
- ☐ Imaging (CT or MRI)
- ☐ NIHSS
- ☐ GCS
- ☐ Labs: CBC, Platelets, Chemistries, PT/PTT, INR, glucose
- ☐ Age
- ☐ Time of Onset
- ☐ NIHSS
- ☐ Imaging findings: primary haemorrhage, ischaemia, or normal scan
MedPearls · Neuro Series 1
ENLS · Ischaemic Stroke Protocol V1.2
Acute Ischaemic Stroke
TIA · Time windows · tPA eligibility · BP management · Endovascular · Admission orders
Acute Ischaemic Stroke — CT/MRI: No haemorrhage or shows ischaemic infarctEstablish IV access · O₂ sat >94% · NIHSS within 5 min · Activate stroke code
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✅ TIA — Symptoms Completely Resolved
TIA: focal neurological symptoms explainable by vascular cause, resolving within 24 hours
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🟢 LOW RISK TIA — ABCD² 0–3
- Antithrombotic: ASA 81 mg/day, Clopidogrel 75 mg/day, or ASA/extended-release dipyridamole
- Carotid imaging: ultrasound, CTA or MRA
- Consider echocardiography
- If A-fib on ECG/rhythm strip → consider oral anticoagulation or LMWH (or ASA 81 mg if contraindicated)
- Consider long-term cardiac monitoring if TIA embolic and A-fib not yet identified
- Smoking cessation · Initiate statin
🔴 MODERATE/HIGH RISK TIA — Admit for Observation
- Permissive hypertension (not to exceed 220/120 mmHg)
- Telemetry
- ASA 81 mg/day, Clopidogrel 75 mg/day or ASA/extended-release dipyridamole — unless A-fib detected
- If A-fib: consider oral anticoagulation, IV heparin or LMWH, or ASA 81 mg/day if contraindicated
- Carotid imaging: ultrasound, CTA or MRA · Consider echocardiography
- Smoking cessation · Initiate statin
🔴 ACUTE ISCHAEMIC STROKE — Deficits Persist
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⏱ < 3 HOURS — IV tPA Eligible Window
All must be met for inclusion
- Diagnosis of ischaemic stroke causing measurable neurological deficit
- Neurological signs NOT clearing spontaneously (treat stuttering/partial improvers)
- Signs NOT minor and isolated — consider any NIHSS if deficit is devastating (isolated aphasia, hemianopsia, brainstem)
- Caution with major deficits
- Symptoms NOT suggestive of subarachnoid haemorrhage
- BP < 185/110 mmHg (or reducible to this)
- Head trauma or prior stroke in previous 3 months
- MI in previous 3 months
- GI or urinary tract haemorrhage in previous 21 days
- Major surgery in previous 14 days
- Arterial puncture at non-compressible site in previous 7 days
- History of previous intracranial haemorrhage
- Active bleeding or acute trauma (fracture)
- Oral anticoagulant with INR > 1.7
- Direct thrombin inhibitors or Xa inhibitors (use 2-day cutoff if no lab available)
- Heparin in previous 48h with aPTT not in normal range
- Platelet count < 100,000 mm³
- Blood glucose < 50 mg/dL (2.7 mmol/L)
- Seizure with postictal neurological impairment
- CT shows multilobar infarction (hypodensity >1/3 cerebral hemisphere)
- Patient/family do not understand risks and benefits
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✓ BP ACCEPTABLE — Administer IV tPA
IV t-PA (Alteplase) — Dose Protocol
Dose: 0.9 mg/kg IV — MAX 90 mg total
1. Place 2 peripheral IV lines
2. WEIGH patient accurately — do not estimate
3. Mix (do not shake) 0.9 mg/kg
4. 10% as IV bolus over 1–2 minutes
5. Remaining 90% infused over 1 hour
Dispensed in 50 and 100 mg bottles — draw off and discard excess to avoid overdose
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Monitoring
- Neuro check q30 min × 6h, then q1h
- O₂ sat >94%
- BP q15 min × 2h, then q30 min × 6h, then q1h × 16h
- BP after reperfusion: <180/105 mmHg
- No tPA given: permissive <220/120 mmHg
- Avoid indwelling urinary catheter, NG tubes, intra-arterial catheters for 4 hours
- No anticoagulant/antiplatelet for 24 hours
- Repeat head CT or MRI at 24h before starting anticoagulant/antiplatelet meds
- Bedside swallow test (30 mL water PO) before anything PO
- Glucose <140 — consider insulin drip
- IVF (NS) for euvolemia · Monitor for A-fib · Treat fever with antipyretics
- Avoid indwelling urinary catheter (nosocomial infection risk)
- Angioedema → airway obstruction → consider rapid intubation
- Haemorrhage → STOP tPA immediately
- Sudden neurological deterioration → likely ICH (often with marked BP rise)
- Severe hypertension or hypotension → may signal ICH or systemic haemorrhage
- STOP tPA infusion immediately
- STAT head CT
- Notify neurosurgeon on call — transfer if not available
- STAT labs: PT, PTT, Platelets, fibrinogen, type and cross 2–4 units PRBCs
- Give: 6–8 units cryoprecipitate + 6–8 units platelets
- Consider: 40–80 mcg/kg recombinant Factor VIIa while waiting
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✓ IMPROVED
🟢
Hospital admission or transfer to stroke unit/ICU. Patient outcomes improve in a stroke centre.
✗ NO IMPROVEMENT
No improvement: no change in NIHSS within 1 hour, or <4-point improvement with debilitating symptoms remaining
- Large vessel occlusion (MCA, intracranial ICA, basilar, vertebral) within 8-hour window
- Suspected by hyperdense sign on CT (insensitive) — confirmed by CTA, MRA, or conventional angiography
- Contact neurointerventional physician — if not available, consider rapid transfer to comprehensive stroke centre
- Some centres use CT/MR perfusion to select patients (ischaemic penumbra)
✗ BP ≥ 185/110 — Reduce BP Before tPA
⚠️
BP too high for tPA — requires gentle reduction before initiating. Always start a drip — boluses wear off.
Labetalol
10 mg IV every 10 min
Consider doubling: 10→20→40→80 mg
Max total: 150 mg
Start maintenance infusion
Nicardipine
Start: 5 mg/h IV
Titrate up 2.5 mg/h every 5–15 min
Max: 15 mg/h
When target reached: reduce to 3 mg/h
If BP falls below 185/110 → proceed to tPA. If BP refractory → do NOT give tPA. Continue to treat BP <220/120 mmHg. Permissive HTN up to 220/120 for TIA and non-tPA patients.
⏱ 3–4.5 HOURS — Extended Window
Note: tPA not yet approved in US for 3–4.5h use; approved in Europe and Canada. Same criteria as <3h plus additional restrictions:
- Age < 80 years
- No anticoagulant use, regardless of INR
- NIHSS ≤ 25
- No combined history of prior stroke AND diabetes
⏱ 4.5–8 HOURS — Outside IV tPA Window
⚠️
Beyond 4.5 hours, IV tPA is associated with ICH — do not give tPA
- IA therapies (mechanical thrombectomy) may be helpful within 8-hour window
- Contact neurointerventional physician — if not available and large vessel occlusion suspected, consider rapid transfer
IV tPA Exclusions
- Time >4.5 hours
- Contraindications (recent surgery, active bleeding at non-compressible site)
- Large area of infarction already present (>1/3 MCA territory)
- No large vessel occlusion on CTA/MRA
- Lack of consent from patient or surrogate
- Large area of infarction already present
- If IA not available but large vessel occlusion suspected → consider rapid transfer to comprehensive stroke centre
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- Transfer if treating hospital cannot provide required level of care (no ICU)
- Transfer if large vessel occlusion evidence and patient can arrive and be treated within 8 hours of onset
- Patient outcomes improve if treated in a stroke centre
MedPearls · Neuro Series 1
ENLS · Intracerebral Haemorrhage Protocol V1.1
Intracerebral Haemorrhage (ICH)
BP targets · Coagulopathy reversal · ICH score · Surgery · Seizures · ICP
ICH Diagnosis ConfirmedSudden headache + progressive neurological signs · Cannot clinically distinguish ICH from ischaemia — emergent brain imaging is essential
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🏥
Immediate — NeuroICU Admission Preferable
- Primary and secondary interventions may be conducted concurrently
- Primary = what can be done now · Secondary = ongoing management
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- ICH may continue to expand — mental status and airway may become compromised
- Continuous airway assessment is critical — especially in posterior fossa haemorrhages
- Intubate if: not protecting airway, hypoventilation, hypoxaemia, declining GCS
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🎯
Target: Keep SBP < 140 mmHg
Nicardipine IV (preferred)
Start: 5 mg/h IV
Titrate 2.5 mg/h every 5–15 min
Max: 15 mg/h
Labetalol IV
20 mg IV bolus
Then as needed to maintain SBP < 140 mmHg
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Determine where the haemorrhage is located — may be more than one site:
- Lobar · Basal ganglia · Thalamus · Cerebellum
- Midbrain · Pons · Intraventricular
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Formula: A × B × C ÷ 2
- Select CT slice with largest ICH
- A = longest axis (cm)
- B = longest axis perpendicular to A (cm)
- C = number of slices × slice thickness (cm)
- Estimated volume of spheroid — correlates well with planimetric CT analysis (Kothari et al, Stroke 1996)
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If IV contrast was administered during CT, extravasation of contrast within the haematoma may suggest active bleeding — this is the CT "Spot Sign" seen on CTA or post-contrast imaging. Indicates risk for haematoma expansion.
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↓
Consider: oral/parenteral anticoagulants, antiplatelet agents, DIC
Warfarin / Vitamin K Antagonists — INR > 1.4
DOACs — Direct Thrombin Inhibitors / Xa Inhibitors
- 4-factor PCC (preferred over FFP) + Vitamin K 10 mg IV
- Dose formula: (Target %PC − Current %PC) × weight kg = mL of FFP or IU of PCC
| INR Range | % Prothrombin Complex Function |
|---|---|
| > 5 | 5% |
| 4.0–4.9 | 10% |
| 2.6–3.9 | 15% |
| 2.2–2.5 | 20% |
| 1.9–2.1 | 25% |
| 1.7–1.8 | 30% |
| 1.4–1.6 | 40% |
| 1.0 | 100% |
Example: INR 7.5, target INR 1.5, weight 80 kg → (40−5) × 80 = 2,800 mL FFP or 2,800 IU PCC
- No specific reversal agents — consider activated charcoal if last dose within 8 hours
- Dabigatran: consider rVIIa 80 µg/kg
- Rivaroxaban or Apixaban: consider PCC 30 IU/kg
- FFP and Vitamin K are NOT effective for DOACs
- Protamine sulfate 1 mg per 100 U heparin received in last 2 hours — maximum dose 50 mg
- Transfuse with platelets
- Consider DDAVP 0.3 mcg/kg IV
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- Do NOT administer anticonvulsants prophylactically
- Treat clinical seizures with benzodiazepines then anticonvulsants
- Consider EEG monitoring if level of consciousness is less than expected by size and location of haemorrhage
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- Consider ICP monitoring if GCS < 8 or patient has symptomatic hydrocephalus
- Large haematoma, intraventricular extension, or hydrocephalus = elevated risk
- See ENLS: Elevated ICP and Herniation protocol for management
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- Cerebellar ICH — consider surgery urgently depending on size
- Lobar ICH with mass effect — consider surgery in severely affected but salvageable patients, and as a life-saving measure in patients who are herniating
- Urgent neurosurgical consult for cerebellar haemorrhage and large haematomas with mass effect
MedPearls · Neuro Series 1
ENLS · Subarachnoid Haemorrhage Protocol V1.1
Subarachnoid Haemorrhage (SAH)
Clinical features · CT/LP diagnosis · Initial orders · BP · Hydrocephalus · Antifibrinolytics · Pain · Seizure
SAH most commonly from trauma, then ruptured intracranial aneurysm. Prevention of re-rupture can be life-saving.
Classic Presentation — Aneurysmal SAH
- Abrupt onset sudden severe headache — onset typically <1 second ("thunderclap")
- NEW, qualitatively DIFFERENT headache for the patient
- May have neck pain, nausea and vomiting
- May transiently lose consciousness or present in coma
- Nature and onset of headache is the key distinguishing feature from other stroke, syncope, seizure
- Headache not reported as abrupt (patient may not remember clearly)
- Headache responds well to non-narcotic analgesics
- Headache resolves spontaneously within hours
- ~40% of SAH patients have a normal neurological examination — may not have meningismus — do not necessarily appear acutely ill
- Glasgow Coma Scale (GCS)
- Pupil exam · Fundoscopic exam for retinal haemorrhages · Neck for meningismus
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See Stroke Triage tab for prehospital protocol.
Indications for Intubation
- Not protecting airway · Hypoventilation · Hypoxaemia
- Expected decompensation during transport within or between hospitals
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📷
Non-contrast CT — Gold standard for SAH (Class 1, LOE B)
- Most sensitive in first hours — by 3 days, only ~85% sensitive
- False negative causes: anaemia, low-volume SAH, technically poor scan
- CTA at time of CT may help identify intracranial aneurysm — but negative CTA alone does NOT rule out SAH
- MRI useful if imaging done days after SAH — specific sequences can detect subarachnoid blood
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✓ CT CONFIRMS SAH
✅
SAH confirmed — LP not necessary. Proceed to initial orders and management.
✗ CT NEGATIVE — LP Mandatory
CT sensitivity for recent SAH ~95% — you can miss 5 in 100 with CT alone. If clinical suspicion, LP is obligatory (Class 1, LOE B).
LP done to look for xanthochromia — staining of CSF by heme breakdown products (chiefly bilirubin). Takes several hours to develop after bleed.
Typical SAH Findings in CSF
- RBCs present
- <5 WBCs · WBC:RBC ratio 1:700
- Xanthochromia present
- Minimal clearing of RBCs between tubes 1 and 4
- Xanthochromia present → SAH confirmed (false positive if CSF protein >100 mg/dL)
- Clear CSF, no xanthochromia → SAH highly unlikely; but if you still clinically suspect aneurysm → emergent consultation
- RBCs in tube 1 and 4 equally, LP done in first few hours → SAH likely
- Clearing from tube 1 to 4 → may be traumatic tap
- RBCs tubes 1 and 4 equal but LP done within 4h → cannot distinguish SAH vs traumatic tap
- No xanthochromia but LP >12h after headache → bleed may have been too small
- Excessive WBCs (WBC:RBC >1:700) → suggests meningitis or encephalitis
Time dependency: CT most sensitive early; RBCs in CSF seen early and clear with time; xanthochromia absent early, nearly always present by 12h after bleed
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✅
SAH Confirmed (by CT or LP)
- Goal: reduce chance of aneurysm re-rupture, expedite aneurysm treatment, prevent medical complications
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↓
- Bed rest (Class 2B, LOE B)
- Pre-operative labs: CBC, Platelets, PT/PTT, electrolytes, BUN, Cr, cardiac enzymes
- 12-lead ECG
- Cardiac telemetry
- Nimodipine 60 mg PO/NG — watch for hypotension
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🎯
Preferred — Short-acting, TitratableTarget: SBP < 140–150 mmHg
- Many specialists recommend SBP <140 in patients with no history of hypertension
- SBP >150 has been associated with aneurysmal re-rupture
- Over-treatment of BP can lead to brain ischaemia — especially if hydrocephalus present
- Labetalol IV
- Nicardipine IV
- Avoid long-term nitroprusside — concern of raising ICP
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- Caused by blockage of CSF absorption — diagnosed on head CT (dilated ventricles)
- If obtunded or comatose → EVD (external ventricular drain) by neurosurgeon or neurointensivist — treats hydrocephalus and monitors ICP
- If no neurosurgeon available: Mannitol 1 g/kg and expedite transfer to neurosurgical facility within the next hour
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- Amicar or tranexamic acid can reduce aneurysmal re-rupture
- Risk: raise risk of DVT, PE, ischaemic stroke if continued
- If free of recent MI, DVT/PE, or hypercoagulable state → many centres administer until aneurysm secured (Hillman et al, J Neurosurg 2002)
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Straining, Valsalva, writhing can cause aneurysm re-rupture. Do NOT over-sedate — could mask hydrocephalus symptoms.
- IV medications with short half-lives — Fentanyl IV
- Liberal anti-emetics if vomiting occurs
- BP control is enhanced with adequate analgesia
- Anxiety: small doses Lorazepam IV
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- PRO: Seizures before definitive aneurysm treatment → associated with re-rupture and raised ICP
- CON: Phenytoin use associated with worse cognitive outcomes
- One strategy: loading dose phenytoin in ED, continue until aneurysm secured, then stop unless seizures have occurred (Class 2B, LOE B)
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Early (within first hour) neurological decompensation:
- Re-rupture of aneurysm → repeat head CT diagnostic
- Worsening hydrocephalus → repeat head CT, EVD urgently needed, give Mannitol while arranging EVD
- Seizure → treat with phenytoin load
- Cardiopulmonary cause → neurogenic pulmonary oedema, catecholamine cardiomyopathy; worsening hypoxia (get CXR); falling BP → urgent echocardiogram; cardiovascular collapse may signal cerebral herniation from re-rupture or untreated hydrocephalus
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- Platelet count <50,000 → administer 6-pack platelets
- Warfarin/Vitamin K antagonists: 4-factor PCC (preferred) or FFP + Vitamin K 10 mg IV
- DOACs: same approach as ICH — see ICH tab
MedPearls · Neuro Series 1
Interactive Calculators & Reference Scales
Scoring Tools
ABCD² · ICH Score · GCS · Hunt-Hess · WFNS · NIHSS
🫀 ABCD² Score — TIA Stroke Risk
Score: 0 — Low Risk (0–3)
| Risk | Score | 2-day % | 7-day % | 90-day % |
|---|---|---|---|---|
| Low | 0–3 | 1.0 | 1.2 | 3.1 |
| Moderate | 4–5 | 4.1 | 5.9 | 9.8 |
| High | 6–7 | 8.1 | 12 | 18 |
Ref: Cucchlara B et al, Ann Emerg Med 2008, 52:S27-39
🩸 ICH Score Calculator
Score: 0 / 6
| Component | Response | Score |
|---|---|---|
| Eye Opening (E) | Spontaneous | 4 |
| To voice | 3 | |
| To pain | 2 | |
| None | 1 | |
| Verbal (V) | Oriented | 5 |
| Confused | 4 | |
| Words only | 3 | |
| Sounds only | 2 | |
| None | 1 | |
| Motor (M) | Obeys commands | 6 |
| Localises pain | 5 | |
| Withdraws | 4 | |
| Flexion (decorticate) | 3 | |
| Extension (decerebrate) | 2 | |
| None | 1 |
Total GCS = E + V + M · Range 3–15 · GCS ≤8 = severe brain injury / consider ICP monitoring
| Grade | Clinical Features |
|---|---|
| 1 | Asymptomatic, mild headache, slight nuchal rigidity |
| 2 | Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy |
| 3 | Drowsiness/confusion, mild focal neurologic deficit |
| 4 | Stupor, moderate-severe hemiparesis |
| 5 | Coma, decerebrate posturing |
| Grade | GCS | Motor Deficit |
|---|---|---|
| 1 | 15 | Absent |
| 2 | 13–15 | Absent |
| 3 | 13–15 | Present |
| 4 | 7–12 | Present or absent |
| 5 | 3–6 | Present or absent |
| Item | Domain | Range |
|---|---|---|
| 1a | Level of consciousness | 0–3 |
| 1b | LOC questions | 0–2 |
| 1c | LOC commands | 0–2 |
| 2 | Best gaze | 0–2 |
| 3 | Visual fields | 0–3 |
| 4 | Facial palsy | 0–3 |
| 5a/5b | Motor arm (left/right) | 0–4 each |
| 6a/6b | Motor leg (left/right) | 0–4 each |
| 7 | Limb ataxia | 0–2 |
| 8 | Sensory | 0–2 |
| 9 | Best language | 0–3 |
| 10 | Dysarthria | 0–2 |
| 11 | Extinction/Inattention | 0–2 |
Total range: 0–42 · 0=no stroke · 1–4 minor · 5–15 moderate · 16–20 moderate-severe · 21–42 severe
MedPearls · Neuro Series 1
ENLS Checklists & Communication Points
Clinical Checklists
Acute Stroke · Ischaemic Stroke · ICH · SAH — all in one place with quick BP reference
Checklist
- ☐ Establish time of onset (time last seen normal)
- ☐ Vital Signs
- ☐ Imaging (CT or MRI)
- ☐ NIHSS
- ☐ GCS
- ☐ Labs: CBC, Platelets, Chemistries, PT/PTT, INR, glucose
- ☐ Age
- ☐ Time of Onset
- ☐ NIHSS
- ☐ Imaging findings: primary haemorrhage, ischaemia, or normal scan
Checklist
- ☐ Vital signs
- ☐ Medication list — especially anticoagulants (warfarin, heparin, LMWH, dabigatran, apixaban, rivaroxaban) and when last taken
- ☐ Labs: capillary glucose, CBC with platelets, PT/PTT, INR, EKG, beta-HCG (women)
- ☐ IV access
- ☐ O₂ to maintain saturation >94%
- ☐ Activate stroke code system (if available)
- ☐ Determine NIHSS score
- ☐ Age
- ☐ Airway status
- ☐ Time of symptom onset
- ☐ NIHSS
- ☐ CT or MRI results
Checklist
- ☐ Check PT, PTT, INR
- ☐ Head Imaging Results: Haematoma volume (ABC/2)
- ☐ GCS
- ☐ Calculate ICH Score
- ☐ Age
- ☐ ICH Volume
- ☐ GCS
- ☐ ICH Score
- ☐ Hydrocephalus present?
Checklist
- ☐ Brain Imaging (non-contrast CT head)
- ☐ Labs: PT/PTT, CBC, electrolytes, BUN, Cr, troponin
- ☐ 12-lead ECG
- ☐ LP if CT negative and clinical suspicion remains
- ☐ Clinical presentation: level of consciousness, motor exam, pupil exam
- ☐ WFNS score and Hunt-Hess Grade
- ☐ Imaging/LP results
- ☐ Hydrocephalus present?
- ☐ Airway status
- ☐ Sedation and other medications given
- ☐ Coordination of other vascular imaging (CTA/MRA/angiography)
| Syndrome | BP Target | Preferred Agents |
|---|---|---|
| AIS — Pre-tPA | < 185/110 | Labetalol, Nicardipine |
| AIS — Post-tPA | < 180/105 | Labetalol, Nicardipine |
| AIS — No tPA | < 220/120 (permissive) | Avoid aggressive lowering |
| ICH | SBP < 140 | Nicardipine ± Labetalol IV |
| SAH | SBP < 140–150 | Labetalol, Nicardipine (avoid long-term nitroprusside) |
MedPearls · Neuro Series 1