Code stroke

Welcome to Audioboards, in this episode we break down a systematic bedside approach to acute stroke activations for internal medicine residents, fully integrating the latest 2026 AHA/ASA guidelines. We strip away the fluff to focus on the operational shift toward single-bolus Tenecteplase (TNK), how tissue-perfusion imaging extends the thrombolytic window up to 9 hours, and the critical neuro-protective parameters you must manage on the floor. 

Transcript

Welcome back to AudioBoards, your high-yield clinical review for internal medicine residents. Today we are talking about one of the highest-stakes activations you’ll face on call: the Code Stroke.

That’s right. When that pager goes off, your adrenaline spikes, but your execution needs to be systematic. Today, we’re integrating the brand-new Acute Ischemic Stroke Guidelines. We’re trimming the fat and focusing purely on the clinical pearls you need at the bedside. Let’s dive in.

Segment 1: The Initial Approach & Bedside Evaluation

You run to the emergency department or the inpatient floor. What is the very first piece of data you need to establish?

The Last Known Normal (LKN) time, or last known well. Everything in stroke management hinges on this clock. If the LKN is within 24 hours and the patient has persistent focal neurological deficits, a Code Stroke is fully live.

Right. And while you are establishing that timeline, you are concurrently performing a rapid focal exam. Don’t get bogged down in a full comprehensive neuro exam initially. Look for the classics: unilateral weakness, sensory loss, facial droop, aphasia, dysarthria, vision loss, or sudden ataxia.

Exactly. While you examine, your nursing team needs to hit a few immediate targets:

Yes, first, Two large-bore IVs. 2. STAT point-of-care fingerstick glucose. This is critical because hypoglycemia is a notorious stroke mimic. If the blood sugar is 40, fix that before you do anything else.

Second, Keep the Head of Bed (HOB) flat if tolerated, to maximize cerebral perfusion, and make sure they are strictly NPO to prevent aspiration.

Now Segment 2: Neuroimaging Demystified

Yes, Once the bedside assessment is done, the patient goes straight to the scanner. The absolute first-line imaging is a STAT Non-Contrast Head CT (NCCT). What is the main goal here?

Rule out a hemorrhagic stroke. Thrombolytics are a hard "no" if there is blood. According to the guidelines, your goal is to have that CT interpreted within 45 minutes of the patient's arrival or code activation.

But the imaging doesn't stop there anymore. The modern protocol relies heavily on CTA (CT Angiography) of the head and neck to look for a Large Vessel Occlusion (LVO), and CT Perfusion (CTP).

Yes, and this is where the 2026 AHA Guidelines really shine. We’ve officially shifted from a rigid, purely time-based paradigm to a tissue-based paradigm.

Can you break that down?

Absolutely. If a patient is within the classic 4.5-hour window with a disabling deficit, you give thrombolytics right away based on the non-contrast CT—no advanced perfusion imaging should delay you. However, if they are in the extended window (4.5 to 9 hours), or if it's a "wake-up stroke" where the LKN is unknown, you look at the CTP or a rapid-sequence MRI. If there is a "mismatch"—meaning a small ischemic core but a large area of salvageable tissue (the penumbra)—they are still candidates for IV thrombolysis!

Segment 3: Thrombolytics & The 2026 Shift

Let's talk about the actual clot-busting medications. There is a massive operational change in the 2026 updates regarding the drug of choice.

Huge change. The 2026 guidelines now firmly endorse Tenecteplase (TNK) right alongside Alteplase (tPA) as a Class 1 recommendation for the 4.5-hour window. In fact, many hospital systems are switching entirely to TNK.

Why the preference shift?

Operational simplicity. Alteplase requires a weight-based bolus followed by a continuous 60-minute infusion.Tenecteplase is a single IV bolus (0.25 mg/kg) given over 5 seconds. It dramatically simplifies transitions of care, especially if you need to transfer the patient for thrombectomy.

Now, before you push that bolus, you have to screen for contraindications. The 2026 guidelines shifted from a rigid checklist to a gradient of risk system.

Right, it's color-coded in practice. Conditions like an unruptured intracranial aneurysm, a history of GI bleeding, or being a "stroke mimic" are now viewed lighter on the risk scale—meaning the benefit of saving brain tissue generally outweighs the risk.

But the hard, non-negotiable contraindications remain: active internal bleeding, intracranial hemorrhage on the current CT, recent severe traumatic brain injury, or an intra-axial intracranial neoplasm. Also, a quick clinical pearl: unless you highly suspect coagulopathy or the patient is on warfarin/heparin, do not wait for the INR or platelet count to come back before starting thrombolytics. Start the infusion. If the labs come back abnormal later, you can stop it.

Segment 4: Endovascular Thrombectomy (EVT)

What if the CTA shows an LVO—like an occlusion in the internal carotid or middle cerebral artery?

Then you call neurointerventional radiology immediately for an Endovascular Thrombectomy (EVT). The 2026 guidelines have expanded EVT eligibility significantly.

For patients presenting 6 to 24 hours from LKN with an anterior circulation LVO, EVT is standard of care if advanced imaging confirms salvageable tissue, even if they have a larger ischemic core than we previously thought safe to touch. There's also a strong recommendation for EVT in basilar artery occlusions within 24 hours if the NIHSS is 10 or higher.

Segment 5: Post-Activation & Inpatient Management Critical Goals

The acute intervention is done, the patient is heading to the Neuro-ICU or specialized stroke unit. Our job as medicine residents now shifts to meticulous neuro-protective parameters. Let's talk about Blood Pressure.

The goals depend entirely on whether they got thrombolytics:

If they received TNK/Alteplase: You must keep the blood pressure strictly < 180/105 mm Hg for the first 24 hours to prevent hemorrhagic transformation.

If they did NOT receive thrombolytics: We allow permissive hypertension up to 220/120 mm Hg to maintain collateral perfusion to the ischemic penumbra.

And a crucial update from the 2026 guidelines: Avoid intensive early blood pressure lowering. Dropping the SBP to less than 140 mm Hg in mild-to-moderate strokes has been shown to offer no functional benefit and can actually cause harm, especially post-EVT. Leave the pressure alone unless it breaches those safety ceilings.

What about glucose and temperature?

Avoid hypoglycemia at all costs, but also avoid over-correcting. The old aggressive target of 80–130 mg/dL is out. The 2026 guidelines state a moderate range of 140–180 mg/dL is perfectly acceptable and safer. Also, treat fevers aggressively with antipyretics because hyperthermia accelerates ischemic brain injury.

For secondary prevention workup within the first 24–48 hours, ensure you order:

An Echocardiogram with contrast (bubble study) to look for an intracardiac thrombus or a Patent Foramen Ovale (PFO).

Continuous telemetry/EKG monitoring to screen for occult Atrial Fibrillation.

Fasting lipids and A1c, targeting an LDL < 70 mg/dL and A1c < 7.0%.

And remember: if the patient did not get thrombolytics and had a minor, non-disabling stroke, do not give them thrombolytics. Instead, start Dual Antiplatelet Therapy (DAPT) immediately.

That wraps up this high-yield review of Code Stroke management. Remember: Last Known Normal determines your pathway, Tenecteplase is your single-bolus friend, tissue-mismatch expands your window, and protects that blood pressure in the first 24 hours.

Thanks for listening to AudioBoards. Stay tuned for more educational content in our next episode! The views and opinions expressed on the AudioBoards Podcast do not necessarily reflect those of our employers. This podcast is for educational purposes only and should not be used to diagnose or treat any medical conditions. It is not a substitute for professional medical advice. Always consult a qualified, board-certified healthcare provider for any medical concern.