A 62-year-old man comes to the emergency department due to right upper extremity weakness. Thirty minutes ago, the patient was at his office when he developed difficulty holding a pen. His grip in the right hand was weak and he could not lift his right arm. He tried calling his coworker but could not speak. The patient has never had similar symptoms before. He had no loss of consciousness, weakness of other extremities, vision abnormality, or headache. The symptoms resolved spontaneously by the time paramedics arrived. Medical history is significant for hypertension and a 30-pack-year smoking history. The patient is a defense attorney and recently took on a high-profile case. Temperature is 36.9 C (98.4 F), blood pressure is 140/84 mm Hg, pulse is 82/min and regular, and respirations are 14/min. Physical examination shows no extremity weakness or sensory loss. There is a left carotid bruit; the remainder of the examination shows no abnormalities. Noncontrast CT scan of the head is normal. Which of the following pharmacotherapies is most appropriate in management of this patient?

Question

A 62-year-old man comes to the emergency department due to right upper extremity weakness.  Thirty minutes ago, the patient was at his office when he developed difficulty holding a pen.  His grip in the right hand was weak and he could not lift his right arm.  He tried calling his coworker but could not speak.  The patient has never had similar symptoms before.  He had no loss of consciousness, weakness of other extremities, vision abnormality, or headache.  The symptoms resolved spontaneously by the time paramedics arrived.  Medical history is significant for hypertension and a 30-pack-year smoking history.  The patient is a defense attorney and recently took on a high-profile case.  Temperature is 36.9 C (98.4 F), blood pressure is 140/84 mm Hg, pulse is 82/min and regular, and respirations are 14/min.  Physical examination shows no extremity weakness or sensory loss.  There is a left carotid bruit; the remainder of the examination shows no abnormalities.  Noncontrast CT scan of the head is normal.  Which of the following pharmacotherapies is most appropriate in management of this patient?

Quizplus · Accepted Answer

This patient with cardiovascular risk factors (ie, hypertension, smoking) and a carotid bruit developed right upper extremity weakness and aphasia that resolved without intervention; this is characteristic of a transient ischemic attack (TIA), which, in this case, likely occured following atheroembolization or low flow from the patient's carotid artery lesion. TIAs are defined as focal neurologic deficits that occur due to transient brain ischemia; tissue infarction does not occur, and brain imaging is normal. Symptoms are typically localized to a singular vascular territory and resolve without intervention, typically in <24 hours. Patients with TIA are at markedly increased risk of future stroke; therefore, intensive medical management is indicated. Secondary prevention includes antiplatelet agents (eg, aspirin, clopidogrel) to prevent thrombus formation and statin therapy (HMG-CoA reductase inhibitor; eg, atorvastatin, rosuvastatin) to reduce atherosclerotic plaque formation. Lifestyle modifications (eg, exercise, tobacco cessation) are also recommended. (Choice A) CNS-targeted immunomodulators (eg, ocrelizumab) or glucocorticoids are used in the treatment of multiple sclerosis (MS), a demyelinating disease that causes relapsing and remitting neurologic deficits. However, MS typically occurs in young women and neurologic deficits are slowly progressive over the course of days. (Choice B) Benzodiazepines (GABA A receptor modulators) are used for acute seizure termination. Seizures can cause postictal paralysis but are typically preceded by stereotyped positive symptoms (eg, repetitive limb movement, lip smacking), whereas TIAs often typically cause negative symptoms (eg, loss of limb function, aphasia). In addition, seizure patients often have postictal confusion or sedation. (Choice D) Selective serotonin reuptake inhibitors are used for treating anxiety or depression. (Choice E) Tissue plasminogen activator ([TPA]; eg, alteplase) is used for thrombolysis in patients with acute, potentially debilitating, ischemic stroke, which would present with persistent neurologic deficits. TPA is not indicated as this patient's symptoms resolved without intervention. Educational objective: Transient ischemic attacks (TIAs) are transient episodes of focal neurologic impairment that occur due to local brain ischemia; tissue infarction does not occur, and brain imaging is normal. Patients with TIA are at increased risk of future stroke; secondary prevention includes antiplatelet agents (eg, aspirin, clopidogrel), statins, and lifestyle modifications (eg, tobacco cessation, exercise) to reduce future risk.

A 62-Year-Old Man Comes to the Emergency Department Due to Right