1. Ischemic stroke
   1. Atherosclerosis
   2. Cardioembolic
2. Hemorrhagic stroke 

1. Large-artery atherosclerosis (Acute thrombosis / Embolus) ; 52%
2. Small vessel occlusion (Lacunar infarction) จาก DM ; 23%
3. Cardioembolism จาก AF , Valve ; 22%
4. Stroke of other determined etiology
   • Hypercoagulable disorder
   • Venous sinus thrombosis
   • Vasculitis
5. Stroke of undetermined etiology (มีมากกว่า 2 สาเหตุ)

1. Abrupt onset of hemiparesis, monoparesis, quadriparesis
2. Hemisensory deficits
3. Visual field deficits
4. Diplopia
5. Dysarthria
6. Facial droop
7. Ataxia
8. Vertigo
9. Aphasia
10. Sudden decrease in the level of consciousness

1. Acute care (door to  rTP  4 hr 30 min )
   1. Thrombolysis therapy

      1. 0.9 mg/kg (maximum 90 mg) IV drip in 60 min,
         แบ่งให้ 10% ___ IV load in 1 min

      2. Control BP < 185/110 mmHg

      3. Measure BP and neuro exam
         q 15 min after rt-PA for 2 hr,
         q 30 min for 6 hr then hourly until 24 hr

      4. Follow-up CT or MRI scan at 24 hr after rt-PA

      5. แพ้ rTPA
         1. A-B-C-D
         2. Discontinue IV rt-PA
         3. Methylprednisolone 125 mg IV stat
         4. diphenhydramine 50 mg IV statRanitidine 50 mg IV (or famotidine 20 mg IV)If there is further increase in angioedema, --> Epinephrine (0.1%) 0.3 mL SC
      6.  bleeding หลังได้ rTPA
         1. Stop alteplase infusion
         2. CBC, PT, INR, aPTT,
         3. Fibrinogen level,
         4. Type and cross-match
         5. CT brain NC Emer
         6. Cryoprecipitate 10 U IV drip in 10 – 30 min ให้ซ้ำหาก fibrinogen level of <200 mg/dL
         7. Transmine (Tranexamic acid) 1000 mg IV drip 10 min
         8. Hematology and neurosurgery consultations
            
            
   2. Aspirin 160-300 mg/day PO 1x1 pc
      or ASA plus Clopidogrel 21 days
      or Clopidogrel alone to 90 days
   3. High intensity statin (Atorvastatin 40-80 mg, Rosuvastatin 20 mg)
   4. Admit stroke unit
   5. Keep SpO2 ≥ 94%
   6. Isotonic iv solution
   7. BP management:
      • rt-PA (180/105 mmHg)
      • non rt-PA (220/120 mmHg)
        
        
   8. Start antihypertensive drug if neurological symptom stable
   9. Blood sugar : 140-180 mg/dl
   10. Cardiac monitoring 24 hr for AF screening
   11. Dysphagia screening
   12. Enteral diet within 7 days, NG tube feeding in patient with dysphagia
   13. Oral hygiene protocol
   14. Depression screening
   15. DVT prevention:
       • early mobilization, intermittent pneumatic compression(IPC)
   16. Cerebral edema
       • Osmotic therapy
       • Mannitol 1.0 g/kg bolus then 0.5 g/kg every 4 - 6 hr
       • Hypertonic saline (0.686 mL/kg of 23.4% saline)
       • Glycerol IV 0.5-1gm/kg
       • Decompressive craniectomy
       • Large MCA infarction
       • Large cerebellar infarction
       • Seizure: No AED prophylaxis
   17. Non-cardioembolic stroke or TIA
       • Antiplatelet agent recommendations:
       • Aspirin (50–325 mg/d) 1x1 po pd (monotherapy)
       • or Clopidogrel (75 mg) 1 x1 po pc
       • or Aspirin plus clopidogrel within 24 hours of a minor ischemic stroke or TIA and continue for 90 days
   18. Cardioembolic stroke (AF, Cardiomyopathy, LV thrombus)
       • Oral anticoagulants (OACs)
         • Warfarin
         • New oral anticoagulants (NOACs) in nonvalvular AF

======[Exclusion Criteria]======

1. NIHSS score ≥ 25 (Sever stroke)
2. Risk factor management
3. Rehabilitation
4. Recent MI in past 3 mo:
   IV rt-PA is reasonable in non-STEMI
   IV rt-PA is reasonable in STEMI (right, inferior, left anterior wall)