A 72-year-old man comes to the emergency department due to right-sided numbness and weakness. The patient says his right side felt numb when he awoke at 5:00 AM, and he was unable to get out of bed due to right arm and leg weakness. The patient called an ambulance and arrived at the emergency department within 45 minutes. He was feeling well with no symptoms when he went to bed last night at 10:00 PM and does not know when his symptoms began. The patient has never had similar symptoms and has no headache, head trauma, fever, or chills. Medical conditions include hypertension and hyperlipidemia, but the patient is nonadherent with medical care and has not seen his primary care physician for the past several years. He has smoked a pack of cigarettes daily for 40 years.
Temperature is 36.5 C (97.7 F), blood pressure is 202/104 mm Hg, and pulse is 84/min and regular. The patient is alert but has frequent word-finding difficulty. Right facial droop is present. Motor strength and sensation to pinprick are decreased in the right upper and lower extremities. Babinski reflex is present on the right. Bedside swallow assessment shows no signs of aspiration.
Noncontrast CT scan of the head reveals no evidence of subarachnoid or intracerebral hemorrhage. Blood cell counts, serum chemistry studies, and coagulation tests are within normal limits. Blood glucose is 120 mg/dL. An ECG shows sinus rhythm with no acute ischemic changes, and chest radiograph is normal.
Which of the following is the most appropriate next step in management of this patient?

Question

A 72-year-old man comes to the emergency department due to right-sided numbness and weakness.  The patient says his right side felt numb when he awoke at 5:00 AM, and he was unable to get out of bed due to right arm and leg weakness.  The patient called an ambulance and arrived at the emergency department within 45 minutes.  He was feeling well with no symptoms when he went to bed last night at 10:00 PM and does not know when his symptoms began.  The patient has never had similar symptoms and has no headache, head trauma, fever, or chills.  Medical conditions include hypertension and hyperlipidemia, but the patient is nonadherent with medical care and has not seen his primary care physician for the past several years.  He has smoked a pack of cigarettes daily for 40 years.
Temperature is 36.5 C (97.7 F), blood pressure is 202/104 mm Hg, and pulse is 84/min and regular.  The patient is alert but has frequent word-finding difficulty.  Right facial droop is present.  Motor strength and sensation to pinprick are decreased in the right upper and lower extremities.  Babinski reflex is present on the right.  Bedside swallow assessment shows no signs of aspiration.
Noncontrast CT scan of the head reveals no evidence of subarachnoid or intracerebral hemorrhage.  Blood cell counts, serum chemistry studies, and coagulation tests are within normal limits.  Blood glucose is 120 mg/dL.  An ECG shows sinus rhythm with no acute ischemic changes, and chest radiograph is normal.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9659_d5b0_853d_af3fb27e1544_MD0002_00 This patient with new focal weakness and head CT scan without evidence of intracranial or subarachnoid hemorrhage has experienced an acute ischemic cerebrovascular accident (CVA). First-line therapy for eligible patients is intravenous thrombolytic therapy (eg, alteplase); however, treatment must be initiated within 4.5 hours of symptom onset. If timing of CVA is unknown, time of onset is when the patient was at last known normal neurologic function (eg, 10:00 PM for this patient). Those outside the 4.5-hour window, such as this patient, are not candidates for thrombolytic therapy (Choices D and E). eligible Mechanical thrombectomy is indicated in those with a large artery occlusion in the anterior circulation and persistent neurologic defects. It can be performed regardless of alteplase administration and should not be delayed to evaluate response to thrombolysis. Thrombectomy must be initiated within the first 24 hours of last known normal status. Therefore, this patient should undergo further evaluation with a CT or MR angiography. Aspirin reduces the risk of recurrent ischemic strokes and should be given within 24-48 hours; however, it should be withheld for 24 hours in patients who undergo thrombolysis. Blood pressure (BP) management is guided by the administration of thrombolytic therapy. In patients who are not candidates for thrombolytic therapy or thrombectomy, permissive hypertension is allowed to maintain perfusion to the ischemic brain. These patients are treated only for extremely elevated BP (systolic BP >220 mm Hg or diastolic BP >120 mm Hg) or if active coronary artery disease, heart failure, aortic dissection, hypertensive encephalopathy, acute renal failure, or preeclampsia/eclampsia are present. Extremely elevated BP is lowered by no more than 15% in the first 24 hours, typically with intravenous antihypertensive agents.Patients who undergo thrombolysis should have BP lowered to <185/110 mm Hg before therapy and maintained at <180/105 mm Hg for at least 24 hours after administration. In patients who are not candidates for thrombolytic therapy or thrombectomy, permissive hypertension is allowed to maintain perfusion to the ischemic brain. These patients are treated only for extremely elevated BP (systolic BP >220 mm Hg or diastolic BP >120 mm Hg) or if active coronary artery disease, heart failure, aortic dissection, hypertensive encephalopathy, acute renal failure, or preeclampsia/eclampsia are present. Extremely elevated BP is lowered by no more than 15% in the first 24 hours, typically with intravenous antihypertensive agents. In patients who are not candidates for thrombolytic therapy or thrombectomy, permissive hypertension is allowed to maintain perfusion to the ischemic brain. These patients are treated only for extremely elevated BP (systolic BP >220 mm Hg or diastolic BP >120 mm Hg) or if active coronary artery disease, heart failure, aortic dissection, hypertensive encephalopathy, acute renal failure, or preeclampsia/eclampsia are present. Extremely elevated BP is lowered by no more than 15% in the first 24 hours, typically with intravenous antihypertensive agents. Patients who undergo thrombolysis should have BP lowered to <185/110 mm Hg before therapy and maintained at <180/105 mm Hg for at least 24 hours after administration. Patients who undergo thrombolysis should have BP lowered to <185/110 mm Hg before therapy and maintained at <180/105 mm Hg for at least 24 hours after administration. (Choices A and B) This patient is not a candidate for thrombolytic therapy and he has no indications for acute blood pressure lowering. In addition, the combination of aspirin and clopidogrel has been shown to increase bleeding risk without improving outcomes in a primary stroke and is not recommended. Educational objective: Thrombolytic therapy is indicated for acute ischemic stroke in patients who are seen within 4.5 hours of symptom onset. Mechanical thrombectomy is indicated for those with a large artery occlusion in the anterior circulation and should be performed within 24 hours of when the patient last had normal function. Aspirin therapy reduces the risk of recurrent ischemic strokes and is recommended within 24-48 hours of the first onset; however, it should be withheld for 24 hours in patients who undergo thrombolysis. __________ 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) Antiplatelet therapy for acute ischemic stroke. (http://www.ncbi.nlm.nih.gov/pubmed/18646056) 2018 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/29367334)

A 72-Year-Old Man Comes to the Emergency Department Due to Right-Sided