Acute Ischemic Stroke & Golden-Hour Thrombolysis Guide
Emergency clinical protocol for acute stroke symptom recognition (B.E.F.A.S.T.), IV thrombolysis with recombinant tPA within 4.5 hours, and mechanical thrombectomy in Delhi stroke-ready hospitals.
Senior Consultant Neurologist, Apollo Hospitals • Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi
- Any sudden unilateral weakness, speech slurring, or facial asymmetry represents an acute medical emergency. Call 108 immediately.
In case of severe acute onset, dial 108 immediately or proceed to the nearest 24/7 Level-1 emergency trauma center.
Zero-Tolerance Emergency Boundary: Acute stroke is a time-critical neurological catastrophe where 1.9 million neurons perish every minute. Any attempt at alternative remedies, homeopathic drops, head massage, or home acupuncture during the acute phase (<24 hours) is clinically negligent and causes irreversible paralysis or mortality. Immediate Level-1 stroke hospital emergency room admission is the sole evidence-based path.
Clinical Background
Acute Ischemic Stroke occurs when an embolus or local thrombus suddenly occludes a major cerebral artery, depriving brain tissue of oxygen and glucose. Up to 1.9 million neurons die every minute an arterial occlusion remains untreated. Immediate transport to a designated Stroke-Ready Center with 24/7 CT/MRI and neurology cover is essential for survival without permanent disability.
Pathophysiology & Disease Progression
Arterial occlusion causes an immediate core of irreversible neuronal infarction, surrounded by an ischemic penumbra—hypoperfused tissue that remains viable for hours if perfusion is restored. Rapid recanalization prevents the penumbra from turning into permanent dead tissue.
Recognized Symptoms
- Balance loss or sudden ataxia and dizziness (B)
- Eyes: Sudden visual disturbance or hemianopia in one or both eyes (E)
- Face Drooping: Asymmetrical smile, facial numbness, or unilateral flattening (F)
- Arm Weakness: Inability to keep both arms raised; drift or numbness in one limb (A)
- Speech Difficulty: Slurred words, expressive aphasia, or inability to comprehend speech (S)
- Time to Call 108: Sudden onset mandates emergency transportation without delay (T)
Etiology & Risk Factors
- Systemic hypertension (>140/90 mmHg) — single largest modifiable risk factor
- Atrial Fibrillation (cardiac arrhythmia causing left atrial thromboembolism)
- Carotid artery stenosis and intracranial atherosclerotic disease (ICAD)
- Diabetes Mellitus, dyslipidemia, and metabolic syndrome
- Cigarette smoking and chronic heavy alcohol use
Recommended Diagnostic Investigations
Evidence-Based Treatment Modalities
Intravenous Thrombolysis (IV tPA / Tenecteplase)
pharmacologicalAdministration of recombinant tissue plasminogen activator within 4.5 hours of symptom onset to dissolve the acute fibrin clot.
Endovascular Mechanical Thrombectomy
interventionalCatheter-directed stent retriever or aspiration retrieval of large vessel occlusions (e.g. M1 segment of MCA, Basilar artery) within 6–24 hours based on CT perfusion mismatch.
Secondary Stroke Prevention Pharmacotherapy
pharmacologicalHigh-intensity statins, antiplatelet therapy (Aspirin/Clopidogrel) or direct oral anticoagulants (DOACs) for atrial fibrillation, and strict blood pressure normalization.
Multidisciplinary Neuro-Rehabilitation
conservativeEarly physical, occupational, and speech swallowing therapy initiated within 48 hours in the stroke ICU.
Frequently Asked Questions
Q:What is the critical 'Golden Hour' window for acute stroke thrombolysis?
Intravenous thrombolysis with recombinant tPA (Tenecteplase/Alteplase) must be initiated within 4.5 hours of documented symptom onset. For large vessel occlusions (LVO), endovascular mechanical thrombectomy can be performed up to 24 hours based on advanced CT perfusion salvageable penumbra imaging.
Q:Why is an immediate Non-Contrast Head CT necessary before giving medicine?
A CT scan immediately differentiates ischemic stroke (clot blocking artery, where blood thinners save brain tissue) from hemorrhagic stroke (bleeding into the brain, where blood thinners cause fatal re-bleeding). Never give aspirin before CT imaging.
Q:What is the difference between a TIA (Mini-Stroke) and a full stroke?
A Transient Ischemic Attack (TIA) is a temporary focal neurological deficit resolving completely within 24 hours (usually <1 hour). However, a TIA carries up to a 15% risk of major disabling stroke within 48 hours and requires urgent emergency hospital evaluation and ABCD2 score risk stratification.
Verified Doctors for Acute Ischemic Stroke & Golden-Hour Thrombolysis Guide
Dr. P. N. Renjen
Senior Consultant Neurologist, Indraprastha Apollo Hospitals
Senior neurologist with 35+ years clinical expertise in stroke management, epilepsy, and neuro-rehabilitation in South Delhi.
All India Institute of Medical Sciences (AIIMS)
Apex Public Healthcare & Research Institute of India
India's premier autonomous super-specialty hospital and medical research institution. 2,478 beds, 24/7 Level 1 Trauma Centre, and cutting-edge quaternary clinical care.
Indraprastha Apollo Hospitals
Flagship Multi-Specialty Quaternary Care Hospital
710-bed quaternary care hospital in South Delhi. First hospital in India to be internationally accredited by Joint Commission International (JCI, USA).