A 65-year-old man comes to the emergency department 2 hours after the onset of weakness in his left arm and leg. Two months ago, he had a 15-minute episode of left arm weakness that resolved spontaneously. He has had no headache, nausea, vomiting, or difficulty swallowing. His medications include chlorthalidone, lisinopril, and metformin. The patient occasionally takes ibuprofen for muscle cramps and antacids for heartburn. His temperature is 36.7 C (98.0 F) , blood pressure is 172/98 mm Hg, and pulse is 83/min with a regular rhythm. Physical examination shows a dense, left-sided hemiparesis. Fingerstick blood glucose is 108 mg/dL. CT scan of the head without contrast shows no signs of intracranial hemorrhage Item 1 of 2
Prior to any further emergency treatment, which of the following should be evaluated in this patient?

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Quizplus · Accepted Answer

Explanation: An acute onset of left-sided weakness is highly suspicious for a stroke in the right middle cerebral artery (MCA) distribution. The patient's episode of temporary left-sided weakness 2 months ago may have been a transient ischemic attack, which indicates an increased risk for stroke in the near future. A head CT imaging study is generally the initial test in patients in whom there is concern for acute stroke. Although early changes of acute cerebral ischemia may not be visualized, imaging helps to eliminate the possibility of intracranial hemorrhage, which requires markedly different management. This patient is still within the 3-4.5-hour window after the onset of symptoms, which potentially renders him eligible for fibrinolytic treatment with tissue plasminogen activator (tPA). However, in addition to excluding intracranial hemorrhage, the patient's risk for bleeding must first be assessed more fully before tPA is administered. Contraindications to fibrinolysis with tPA include: Presence of active internal bleeding Bleeding diathesis (eg, platelets <100,000/µL) Hypodensity in >33% of an arterial territory on CT scan Presence of intracranial hemorrhage on CT scan Intracranial surgery in the last 3 months Blood pressure >185/110 mm Hg (Choice B) Cerebral vasospasm is more commonly associated with subarachnoid hemorrhage and vasculitis. The presence of vasospasm does not affect the decision to begin fibrinolytic treatment. (Choice C) Deep venous thrombosis risk assessment is important for hospitalized patients, but an assessment of the risk of bleeding is more crucial at this point as a decision on fibrinolytic therapy must be made quickly. (Choice D) The patient should be evaluated and treated for arrhythmias such as atrial fibrillation that may have led to the stroke, but assessment of bleeding risk takes precedence at this point. (Choice E) Seizures can be associated with cerebral infarcts. However, seizures are a relative contraindication to fibrinolytic therapy only if the patient has postictal impairment, as there may be diagnostic confusion over whether seizure or stroke is the primary problem. Educational objective: Fibrinolytic therapy with tissue plasminogen activator (tPA) should be considered for patients with symptoms of acute stroke that have been present <3-4.5 hours. A rapid assessment must be performed for bleeding risk (and especially for intracranial hemorrhage), which is a serious concern and a common side effect of tPA administration. Several conditions, including the presence of active bleeding and hypodensity in >33% of an arterial territory on CT scan, are absolute contraindications to tPA administration. References: Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. (http://www.ncbi.nlm.nih.gov/pubmed/23370205)

A 65-Year-Old Man Comes to the Emergency Department 2 Hours