A 65-year-old man is brought to the emergency department with a sudden onset of right-sided weakness and difficulty speaking that began one hour ago. His other medical problems include hypertension and hyperlipidemia. He has no history of stroke, myocardial infarction, recent trauma or surgery, or bleeding. He has smoked 2 packs of cigarettes daily for 30 years. His medications include hydrochlorothiazide, lisinopril, amlodipine, and simvastatin.
His temperature is 37.0 C (98.6 F), blood pressure is 180/100 mm Hg, and pulse is 115/min. On neurological examination, he is awake and alert. He has significant expressive aphasia and difficulty with repetition. He has right-sided hemiparesis (arm leg) and numbness. His reflexes are increased on the right with an extensor plantar response.
His EKG shows an irregularly irregular rhythm and nonspecific T wave changes.
Laboratory results are as follows:

A head CT is negative for hemorrhage. After initial evaluation, he is treated with intravenous tPA.
Which of the following is the most important step in the management of this patient within the next 24 hours?

Question

A 65-year-old man is brought to the emergency department with a sudden onset of right-sided weakness and difficulty speaking that began one hour ago.  His other medical problems include hypertension and hyperlipidemia.  He has no history of stroke, myocardial infarction, recent trauma or surgery, or bleeding.  He has smoked 2 packs of cigarettes daily for 30 years.  His medications include hydrochlorothiazide, lisinopril, amlodipine, and simvastatin.
His temperature is 37.0 C (98.6 F), blood pressure is 180/100 mm Hg, and pulse is 115/min.  On neurological examination, he is awake and alert.  He has significant expressive aphasia and difficulty with repetition.  He has right-sided hemiparesis (arm > leg) and numbness.  His reflexes are increased on the right with an extensor plantar response.
His EKG shows an irregularly irregular rhythm and nonspecific T wave changes.
Laboratory results are as follows:

A head CT is negative for hemorrhage.  After initial evaluation, he is treated with intravenous tPA.
Which of the following is the most important step in the management of this patient within the next 24 hours?

Quizplus · Accepted Answer

This patient is likely presenting with an acute ischemic embolic stroke to the left superior division of the middle cerebral artery secondary to atrial fibrillation. This patient has received IV tPA therapy, and therefore his blood pressure in the first 24 hours must be maintained < 180/105 mm Hg to reduce the risk of intracerebral hemorrhage. (Choice A) Amiodarone is a class III antiarrhythmic that is used for chemical cardioversion of atrial fibrillation. In this case, cardioversion will increase the risk of further cardioembolic events from re-establishment of the atrial kick. (Choice B) Aspirin should be avoided in the first 24 hours after IV tPA administration. Following the initial 24-hour period, aspirin may be started if the repeat non-contrast head CT shows no bleeding and the patient is not a candidate for anticoagulation for the atrial fibrillation. (Choice C) Early enteral feeding is not recommended in patients receiving tPA. These patients need to be kept NPO for at least 24 hours in the event of hemorrhagic conversion requiring possible surgery to lower intracranial pressure. (Choice D) Intravenous heparin infusion may be started only after the first 24 hours following IV tPA if a non-contrast head CT shows no hemorrhagic transformation or a diffusion-weighted MRI of the brain shows no evidence of a large completed infarct (> 33% of cerebral hemisphere). Educational objective: Within the first 24 hours of intravenous tPA treatment, the patient's blood pressure should be maintained < 180/105 mm Hg. Early enteral feeding, anticoagulants, and anti-platelet agents should be avoided for the first 24 hours until repeat CT head imaging shows no hemorrhagic conversion. __________ References: Management of blood pressure after acute ischemic stroke: An evidence-based guide for the hospitalist. (http://www.ncbi.nlm.nih.gov/pubmed/17705177)

A 65-Year-Old Man Is Brought to the Emergency Department with a Sudden