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 The patient receives appropriate therapy. The next day, neurologic examination shows some improvement of the left-sided weakness. Carotid duplex ultrasound scanning shows bilateral atherosclerotic plaques with no significant stenosis, and an electrocardiogram shows normal sinus rhythm. Which of the following is the most appropriate next step in management of this patient?

Question

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 The patient receives appropriate therapy.  The next day, neurologic examination shows some improvement of the left-sided weakness.  Carotid duplex ultrasound scanning shows bilateral atherosclerotic plaques with no significant stenosis, and an electrocardiogram shows normal sinus rhythm.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: After the diagnosis of an acute stroke is made and appropriate treatment is started, further evaluation is necessary to determine the cause of the cerebral infarct: Magnetic resonance or CT angiographycan evaluate the carotids and intracranial vasculature, or duplex ultrasound can evaluate the carotids alone. Electrocardiogram can diagnose myocardial ischemia or arrhythmia that may result in intracardiac thrombus formation and resultant embolus. Transthoracic echocardiogram (TTE)or transesophageal echocardiogram (TEE) can be used to detect intracardiac thrombus. TEE is more sensitive than TTE but is more invasive and therefore difficult to use in patients with acute stroke. Cardiovascular magnetic resonance imaging for evaluation for intracardiac thrombus may be an option for some patients. (Choice B) An electroencephalogram is typically used when there is concern for seizure activity but is not used routinely in acute stroke. (Choice C) Hypercoagulability studies are not indicated in all patients with acute stroke. They should be ordered in those with a personal or family history of hypercoagulable disease, in young patients with no apparent etiology for stroke despite evaluation for vascular and cardiac sources, and in patients with clinical findings that suggest systemic lupus erythematosus. (Choice D) Upper-extremity Doppler studies can detect thrombi but would not be performed routinely in a stroke patient when there is no suspicion for deep vein thrombosis. (Choice E) Lumbar puncture should be considered if there is concern that this patient's neurologic symptoms are secondary to central nervous system infection or multiple sclerosis. Educational objective: All patients with acute stroke should have an evaluation of the heart and neck vessels to rule out possible embolic sources. Ultrasound can be used to evaluate the neck vasculature; CT angiogram or MR angiogram can evaluate both the neck and intracranial vasculature. Electrocardiogram is helpful to evaluate for ischemia and arrhythmia, and a transthoracic echocardiogram is generally recommended to evaluate for the presence of an intracardiac thrombus. References: Transesophageal echocardiography is superior to transthoracic echocardiography in management of patients of any age with transient ischemic attack or stroke. (http://www.ncbi.nlm.nih.gov/pubmed/16946152)

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