Step 3 CCS: Stroke

Stroke CCS cases are time-critical from the first second. You must rapidly differentiate ischemic from hemorrhagic stroke with a non-contrast CT, decide on IV alteplase eligibility within minutes, and manage blood pressure per protocol. Missing the tPA window or giving tPA to a hemorrhagic stroke patient are catastrophic CCS errors that will fail the case.

Clinical Approach — What Attendings Do First

The First Minute

  • STAT non-contrast CT head — must be ordered in the first 60 seconds of the case
  • Fingerstick glucose (hypoglycemia mimics stroke — correct if <60 mg/dL)
  • Check time of symptom onset (or last known well) — this determines tPA eligibility
  • Place on continuous cardiac telemetry (atrial fibrillation is the most common embolic source)
  • Establish IV access, draw CBC, BMP, PT/INR, glucose — but do NOT delay CT

Key Orders

  • CT head without contrast STAT (if hemorrhage excluded, consider CT angiography head/neck)
  • CBC, BMP, PT/INR, troponin, lipid panel, HbA1c, ESR
  • If tPA eligible: alteplase 0.9 mg/kg IV (max 90 mg), 10% as bolus over 1 min, remainder over 60 min
  • Labetalol 10-20 mg IV if SBP >185 pre-tPA (or nicardipine 5 mg/hr IV, titrate q5min)
  • NPO — order swallow evaluation before any oral intake (aspiration risk)
  • Neurology consult STAT
  • Aspirin 325 mg PO — give AFTER 24 hours if tPA was administered, immediately if no tPA

Time-Sensitive Actions

  • CT head within 25 minutes of arrival, read within 45 minutes — CCS mirrors these real benchmarks
  • tPA must be started within 3 hours of symptom onset (4.5 hours in extended-window patients)
  • If large vessel occlusion on CTA and within 6-24 hours: interventional neurology consult for mechanical thrombectomy
  • Swallow screen before any oral intake — aspiration pneumonia is a preventable complication

Common CCS Pitfalls

  • Ordering MRI before CT — delays diagnosis and tPA decision
  • Giving tPA to a hemorrhagic stroke — catastrophic error; CT MUST come first
  • Lowering blood pressure aggressively in non-tPA ischemic stroke — worsens perfusion
  • Giving aspirin within 24 hours of tPA — increases hemorrhagic conversion risk
  • Forgetting swallow evaluation — aspiration pneumonia is a common preventable stroke complication

Frequently Asked Questions

What is the absolute first order in a CCS stroke case?

Non-contrast CT head STAT — ordered before anything else. This single test determines your entire pathway: if CT shows hemorrhage, tPA is absolutely contraindicated. If CT is negative for hemorrhage and symptoms started <3 hours ago (or <4.5 hours in selected patients), the patient is a tPA candidate. Do NOT order MRI first — it delays decision-making. Order CT within the first 1-2 simulated minutes.

What are the tPA inclusion and exclusion criteria for CCS?

Inclusion: ischemic stroke symptoms, CT head negative for hemorrhage, symptom onset <3 hours (<4.5 hours if age <80, no diabetes+prior stroke, NIHSS <25, not on anticoagulants). Exclusions: SBP >185 or DBP >110 after treatment, platelets <100,000, INR >1.7, glucose <50 mg/dL, recent surgery (14 days), prior intracranial hemorrhage, or active internal bleeding. On CCS, check labs before infusing.

How do I manage blood pressure in a CCS stroke case?

For tPA-eligible patients: BP must be <185/110 before administration — use IV labetalol 10-20 mg over 1-2 minutes or nicardipine drip. After tPA: maintain BP <180/105 for 24 hours. For non-tPA ischemic stroke: permissive hypertension up to 220/120 (do NOT lower BP unless end-organ damage). Hemorrhagic stroke: target SBP <140 with nicardipine or clevidipine infusion.

Related Organ System Topics

Neurology

Neurology questions on USMLE Step 3 cover stroke management, seizures, headache syndromes, movement disorders, and dementia.

Emergency Medicine

Emergency medicine on USMLE Step 3 covers the initial evaluation and stabilization of critically ill and injured patients.

Practice Stroke CCS Cases

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