A 65-year-old man with a history of hypertension is brought to the emergency department for acute onset of right-sided weakness and slurred speech, which started an hour ago. He takes no prescription medications and has no history of bleeding.
The patient's blood pressure is 170/96 mm Hg. On examination, he has right lower facial droop, dysarthria, and diminished strength in his right upper and lower extremities.
A non-contrast head CT is negative. His finger stick blood glucose is 90 mg/dL. Intravenous tissue plasminogen activator is administered.
Assuming this patient's symptoms do not resolve rapidly, which of the following is the most appropriate next step in management?

Question

A 65-year-old man with a history of hypertension is brought to the emergency department for acute onset of right-sided weakness and slurred speech, which started an hour ago.  He takes no prescription medications and has no history of bleeding.
The patient's blood pressure is 170/96 mm Hg.  On examination, he has right lower facial droop, dysarthria, and diminished strength in his right upper and lower extremities.
A non-contrast head CT is negative.  His finger stick blood glucose is 90 mg/dL.  Intravenous tissue plasminogen activator is administered.
Assuming this patient's symptoms do not resolve rapidly, which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

Venous thromboembolism (VTE) is responsible for 13%-25% of early deaths after stroke and typically occurs 2-4 weeks after stroke onset. This patient has an acute ischemic stroke and appropriately received tissue plasminogen activator (tPA) but still has impaired mobility, putting him at higher risk for VTE. Although he would benefit from anticoagulants and aspirin, they are not to be given <24 hours after starting tPA due to an increased risk of symptomatic intracranial hemorrhage (Choices A, B, and D). After 24 hours, patients should typically receive a follow-up neuroimaging study (eg, head CT, brain MRI) to rule out intracranial hemorrhage prior to starting anticoagulants or aspirin. Thigh-length intermittent pneumatic compression devices are generally recommended at presentation in these patients. Studies show that low-dose enoxaparin has the highest benefit-to-risk ratio for preventing VTE and avoiding major intracranial/extracranial hemorrhage, in comparison to high-dose enoxaparin and unfractionated heparin. Educational objective: In patients with acute ischemic stroke, aspirin and anticoagulation (for venous thromboembolism prophylaxis) should not be started within 24 hours of initiating tissue plasminogen activator and should generally be preceded by neuroimaging to rule out intracranial hemorrhage. __________ 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) Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/23727163)

A 65-Year-Old Man with a History of Hypertension Is Brought