A 78-year-old woman is brought to the emergency department due to sudden-onset, right-sided hemiplegia and right-sided facial droop. Medical history is significant for chronic kidney disease and hypertension. The patient has a history of medication nonadherence and does not remember the names of her prescribed medications. Temperature is 37 C (98.6 F), blood pressure is 218/128 mm Hg, pulse is 84/min, and respirations are 15/min. On examination, the patient is mildly lethargic but able to converse. Cranial nerve examination shows upper-motor-neuron, right-sided facial weakness. Muscle strength is 0/5 in the right upper and lower extremities. CT scan of the head, immediately performed, is shown in the exhibit.

Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

A 78-year-old woman is brought to the emergency department due to sudden-onset, right-sided hemiplegia and right-sided facial droop. Medical history is significant for chronic kidney disease and hypertension. The patient has a history of medication nonadherence and does not remember the names of her prescribed medications. Temperature is 37 C (98.6 F) , blood pressure is 218/128 mm Hg, pulse is 84/min, and respirations are 15/min. On examination, the patient is mildly lethargic but able to converse. Cranial nerve examination shows upper-motor-neuron, right-sided facial weakness. Muscle strength is 0/5 in the right upper and lower extremities. CT scan of the head, immediately performed, is shown in the exhibit.

Laboratory results are as follows:

Which of the following is the best next step in management of this patient?

Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d165_8176_bc81_134ab6dae795_MD0003_00 This patient's acute, right-sided hemiplegia and facial droop are concerning for a stroke. When stroke is suspected, noncontrast CT scan of the head is performed to differentiate between ischemic and hemorrhagic strokes, which require different management. This patient's CT scan reveals a white, hyperdense region within the left basal ganglia consistent with a hemorrhagic stroke. After assessment of the "ABCs" (ie, airway, breathing, circulation), management of hemorrhagic stroke focuses on preventing further bleeding and maintaining normal intracranial pressure (ICP) to reduce the risk for brain herniation (due to postinfarction edema). This typically includes the following: Blood pressure control: Reversible and titratable antihypertensive medications such as intravenous nicardipine or labetalol are used, with a systolic blood pressure goal of 140-160 mm Hg. Reversal of anticoagulation: Targeted reversal of any anticoagulation; vitamin K is typically given to patients on warfarin, and protamine sulfate to patients on heparin. Regulation of ICP: Increased ICP is treated with interventions such as head-of-the-bed elevation, sedation, and osmotic therapy (eg, mannitol). In severe cases, neurosurgical hematoma evacuation may be required; however, this is typically reserved for patients with evidence of impending brain herniation (eg, large hematoma with midline shift on CT scan) or elevated ICP that is refractory to medical management (Choice C). (Choice B) Patients with hemorrhagic stroke can develop significant complications (eg, seizures, brain herniation). Therefore, aggressive management is required to prevent further bleeding and to control ICP; observation is not appropriate. (Choice D) Fresh frozen plasma may be given to replete clotting factors in patients with massive hemorrhage (eg, massive transfusion protocol) or to reverse the anticoagulation effects of warfarin (typically in combination with vitamin K). However, this patient does not have massive hemorrhage and likely has not taken warfarin, given her normal INR. (Choice E) Transfusion of packed red blood cells can improve oxygen delivery to tissues. However, this is not typically done unless there is severe hemorrhage (which does not occur with hemorrhagic stroke due to the limited size of the cranial vault) or hemoglobin is <7 g/dL in critically ill patients. This patient's mild anemia is more likely due to chronic kidney disease than intracranial hemorrhage. Educational objective: Management of hemorrhagic stroke focuses on preventing further bleeding (eg, blood pressure control, anticoagulant reversal) and maintaining normal intracranial pressure. Hypertension is treated with a reversible and titratable antihypertensive (eg, intravenous nicardipine). References: 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 78-Year-Old Woman Is Brought to the Emergency Department Due