A 34-year-old woman comes to the emergency department due to right-sided weakness and difficulty speaking since she awoke 5 hours ago. The patient has no fever, weight loss, fatigue, headache, loss of consciousness, or vision problems. According to her husband, she had a similar episode 6 months ago that resolved quickly and was attributed to her migraine headaches. The patient has had one previous miscarriage at 12 weeks gestation. She smokes a half-pack of cigarettes per day and does not use illicit drugs. The patient has a family history of migraines.
Temperature is 37.2 C (99 F), blood pressure is 143/77 mm Hg, and pulse is 87/min. There are no carotid bruits. Cardiac auscultation reveals no murmurs. There is right hemiparesis and mild expressive aphasia.
Laboratory results are as follows:
ECG shows normal sinus rhythm. CT scan of the head shows no intracranial mass and no evidence of bleeding; CT angiography of the head and neck shows no significant large vessel stenosis or occlusion.
Which of the following is the best next step in management of this patient?

Question

A 34-year-old woman comes to the emergency department due to right-sided weakness and difficulty speaking since she awoke 5 hours ago.  The patient has no fever, weight loss, fatigue, headache, loss of consciousness, or vision problems.  According to her husband, she had a similar episode 6 months ago that resolved quickly and was attributed to her migraine headaches.  The patient has had one previous miscarriage at 12 weeks gestation.  She smokes a half-pack of cigarettes per day and does not use illicit drugs.  The patient has a family history of migraines.
Temperature is 37.2 C (99 F), blood pressure is 143/77 mm Hg, and pulse is 87/min.  There are no carotid bruits.  Cardiac auscultation reveals no murmurs.  There is right hemiparesis and mild expressive aphasia.
Laboratory results are as follows:
 ECG shows normal sinus rhythm.  CT scan of the head shows no intracranial mass and no evidence of bleeding; CT angiography of the head and neck shows no significant large vessel stenosis or occlusion.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_96b1_44e1_853d_6dfa2f7ce808_MD0002_00 This patient with right hemiparesis and aphasia has a stroke that localizes to the middle cerebral artery distribution and is ischemic (vs hemorrhagic) on CT scan of the head. She is outside the treatment window (<4.5 hours) for intravenous thrombolysis and is not a candidate for mechanical thrombectomy because no large vessel occlusion is present on CT angiography. Therefore, the best next step is antiplatelet therapy to reduce the risk of early ischemic stroke recurrence. Although this patient has mild thrombocytopenia (eg, platelets of 90,000/mm³), bleeding risk with antiplatelet therapy is not substantially increased unless platelets are <50,000/mm³. ³ ³ Following administration of antiplatelet therapy, a full stroke evaluation (eg, echocardiography, ECG monitoring, carotid ultrasonography) should be performed. In addition, evaluation for hypercoagulability should be considered in this patient because she has multiple indicators for a possible underlying hypercoagulable disorder, including stroke at a young age (age <50) and history of a late miscarriage (ie, >10 weeks gestation). These factors in combination with an abnormal PTT (which can be caused by a lupus anticoagulant) specifically suggest antiphospholipid syndrome (APS). Thrombocytopenia can occur in APS (~30%-45% of cases), likely from antiphospholipid antibody binding of platelets. antiphospholipid syndrome (Choices B and D) Lumbar puncture can help diagnose multiple sclerosis, which can present with acute neurologic symptoms in a young patient. However, this patient's symptoms are more consistent with ischemia in a cerebral vascular distribution than monofocal or multifocal demyelination from multiple sclerosis. Rather than receiving high-dose corticosteroids to treat MS, she should receive antiplatelet therapy for treatment of a presumptive stroke. (Choice C) Intravenous metoclopramide and ketorolac can treat migraine, which sometimes causes accompanying neurologic deficits. However, a headache (typically severe) is usually present, and thrombocytopenia and prolonged PTT are not expected. (Choice E) Plasma exchange can help treat thrombotic thrombocytopenic purpura (TTP), which can cause thrombocytopenia and focal neurologic symptoms. However, TTP-associated thrombocytopenia is usually severe (eg, platelets <30,000/mm³) and other features of TTP (eg, fever, petechiae, hemolytic anemia) are often present. ³ features of TTP Educational objective: Patients with ischemic stroke who are ineligible for thrombolysis and mechanical thrombectomy should receive antiplatelet therapy to decrease the risk of early recurrent ischemic stroke. A hypercoagulable workup may be considered part of the subsequent stroke evaluation if indicators for a potential underlying hypercoagulable disorder (eg, young age, history of late miscarriage) are present. __________ References: Diagnosis and management of acute ischemic stroke: speed is critical. (http://www.ncbi.nlm.nih.gov/pubmed/26243819) Antiphospholipid antibody syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/21877992)

A 34-Year-Old Woman Comes to the Emergency Department Due to Right-Sided