A 63-year-old woman is brought to the emergency department with left-sided weakness that started an hour ago. According to family members, the patient dropped her fork while having dinner and subsequently was unable to walk. Medical history includes hypertension, hyperlipidemia, and type 2 diabetes mellitus. Examination shows normal S1 and S2 and no carotid bruits. Neurologic examination shows dense, left-sided hemiplegia. After initial evaluation, including a noncontrast CT scan of the head that is negative for hemorrhage, tissue plasminogen activator is administered. The patient is not a candidate for mechanical thrombectomy. Five hours later, the left-sided weakness is improved. The patient has no headache, blurred vision, or nausea. Blood pressure is 198/110 mm Hg and pulse is 87/min and regular. Finger-stick glucose level is 143 mg/dL. Which of the following is the most appropriate immediate next step in management?

Question

A 63-year-old woman is brought to the emergency department with left-sided weakness that started an hour ago.  According to family members, the patient dropped her fork while having dinner and subsequently was unable to walk.  Medical history includes hypertension, hyperlipidemia, and type 2 diabetes mellitus.  Examination shows normal S1 and S2 and no carotid bruits.  Neurologic examination shows dense, left-sided hemiplegia.  After initial evaluation, including a noncontrast CT scan of the head that is negative for hemorrhage, tissue plasminogen activator is administered.  The patient is not a candidate for mechanical thrombectomy.  Five hours later, the left-sided weakness is improved.  The patient has no headache, blurred vision, or nausea.  Blood pressure is 198/110 mm Hg and pulse is 87/min and regular.  Finger-stick glucose level is 143 mg/dL.  Which of the following is the most appropriate immediate next step in management?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bffa_877a_8f63_8983ecfb88ce_MD0005_00 This patient with an acute ischemic stroke (eg, acute left-sided hemiplegia, no hemorrhage on CT scan) has received thrombolysis with tissue plasminogen activator (tPA) and experienced improved symptoms. After thrombolysis, she should be admitted to an intensive care or dedicated stroke unit for close monitoring of the following: Neurologic status: Frequent examinations monitor for neurologic deterioration, which may signal intracerebral hemorrhage, the most feared complication of thrombolysis. Blood pressure: Blood pressure is kept at <180/105 mm Hg to decrease the risk of hemorrhagic transformation. This is best achieved using intravenous antihypertensive agents such as labetalol or nicardipine because they have rapid onset and are easily titratable. Hypotension should also be avoided to maintain adequate perfusion to the ischemic penumbra (ie, hypoperfused brain at risk for infarction). Intensive monitoring also facilitates the recognition and treatment of other possible complications of tPA, such as angioedema or systemic bleeding. Because the risk of bleeding increases following thrombolysis, waiting at least 24 hours is recommended before performing any invasive testing or procedures and before beginning antiplatelet therapy or anticoagulation. (Choices A and C) Full-dose anticoagulation with heparin or oral anticoagulant therapy is contraindicated in the first 24 hours following tPA. In addition, there is no indication (eg, atrial fibrillation, intracardiac thrombus) for anticoagulation in this patient. (Choice D) Antiplatelet therapy (eg, aspirin) is eventually administered to most stroke patients. However, it is contraindicated in the first 24 hours after tPA because it increases the risk of bleeding. It is typically started 24-48 hours after tPA if the patient is stable; some institutions also perform a noncontrast CT scan of the head prior to initiation to confirm that no interval intracerebral hemorrhage has occurred. (Choice E) Oral antihypertensive agents (eg, hydrochlorothiazide) will likely be needed for long-term control of this patient's blood pressure to decrease her risk of future stroke. However, in the early period after tPA administration, intravenous antihypertensive agents are preferred; their rapid onset of action and ability to be quickly titrated help keep the blood pressure <180/105 mm Hg while avoiding hypotension. Educational objective: Patients with acute ischemic stroke who are treated with tissue plasminogen activator should have strict blood pressure control. Blood pressure is kept <180/105 mm Hg using intravenous antihypertensive agents to decrease the risk of hemorrhagic transformation. Hypotension is avoided to maintain adequate perfusion to the ischemic penumbra. References: Critical care management of acute ischemic stroke. (http://www.ncbi.nlm.nih.gov/pubmed/28466119) Complications associated with recombinant tissue plasminogen activator therapy for acute ischaemic stroke. (http://www.ncbi.nlm.nih.gov/pubmed/23394532)

A 63-Year-Old Woman Is Brought to the Emergency Department with Left-Sided