A 62-year-old man is brought to the emergency department due to left-sided weakness, numbness, and difficulty speaking. He was walking his dog about an hour ago when he developed sudden-onset weakness of the left arm. The patient did not lose consciousness. He has hypertension and type 2 diabetes mellitus but no other medical or surgical history. Blood pressure is 170/96 mm Hg, and pulse is 76/min and regular. On examination, his speech is dysarthric and he has left facial droop. The patient's left upper extremity muscle strength is 2/5 and left lower extremity strength is 5/5. Left hemisensory loss is present. He has impaired attention and lack of awareness for stimuli on the left side of space. Finger-stick glucose level is 270 g/dL, and noncontrast CT scan of the head reveals no abnormalities. Recent laboratory studies performed at his primary care provider's office show serum LDL of 152 mg/dL and hemoglobin A1c of 7.9%. Which of the following therapies is the best next step in management of this patient?

Question

A 62-year-old man is brought to the emergency department due to left-sided weakness, numbness, and difficulty speaking.  He was walking his dog about an hour ago when he developed sudden-onset weakness of the left arm.  The patient did not lose consciousness.  He has hypertension and type 2 diabetes mellitus but no other medical or surgical history.  Blood pressure is 170/96 mm Hg, and pulse is 76/min and regular.  On examination, his speech is dysarthric and he has left facial droop.  The patient's left upper extremity muscle strength is 2/5 and left lower extremity strength is 5/5.  Left hemisensory loss is present.  He has impaired attention and lack of awareness for stimuli on the left side of space.  Finger-stick glucose level is 270 g/dL, and noncontrast CT scan of the head reveals no abnormalities.  Recent laboratory studies performed at his primary care provider's office show serum LDL of 152 mg/dL and hemoglobin A1c of 7.9%.  Which of the following therapies is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d167_a458_bc81_e7ca2795ff09_MD0003_00 This patient has had an acute ischemic stroke in the distribution of the right middle cerebral artery (MCA). Right (typically nondominant) MCA infarcts classically present with contralateral hemiparesis (facial > upper > lower) and hemisensory loss, dysarthria (ie, disordered speech due to the facial muscle weakness), and hemineglect (eg, impaired attention and lack of awareness for stimuli on the left side). Patients with symptoms of stroke should receive an emergent CT scan of the head without contrast to rule out hemorrhage because hemorrhagic and ischemic strokes receive different treatment. MCA infarcts treatment Once intracerebral hemorrhage is excluded, thrombolytic therapy should be considered if no absolute contraindications exist. Intravenous alteplase (tissue plasminogen activator) has been shown to improve neurologic outcomes in patients with ischemic stroke when given within 4.5 hours of symptom onset. Because this patient's symptoms began an hour ago, he is a good candidate for thrombolytic therapy. The sooner alteplase is administered, the better the chance of neurologic recovery. (Choice A) Stroke patients with severe hyperglycemia (ie, blood glucose >180 mg/dL) should be treated with insulin because hyperglycemia may worsen brain injury; however, this patient first requires definitive thrombolytic therapy to reestablish circulation to the ischemic brain region. (Choice C) Therapeutic parenteral anticoagulation (eg, intravenous heparin) is not typically used in the acute management of ischemic stroke because it increases the risk of hemorrhagic transformation. Although alteplase also increases risk of hemorrhagic transformation, its rapidity of clot recanalization (vs slow clot dissolution with heparin) provides sufficient benefit to outweigh the risk. (Choice D) Blood pressure should be kept ≤185/110 mm Hg prior to administration of thrombolytic therapy due to the increased risk of intracranial hemorrhage. Labetalol is an alpha-1 and beta-adrenergic receptor blocker that may be used for this purpose; however, it is not necessary in this patient because his blood pressure is below this cutoff. (Choice E) Aspirin may help reduce clot propagation and risk of stroke recurrence if administered within 48 hours of stroke onset; however, intravenous alteplase is more effective than antiplatelet therapy at achieving clot recanalization and neurologic recovery. Educational objective: Thrombolytic therapy (eg, intravenous alteplase) improves neurologic outcomes in patients with acute ischemic stroke when given within 4.5 hours of symptom onset. Before thrombolytics are administered, a noncontrast CT scan of the head should be performed to rule out hemorrhagic stroke, and the patient should be screened for other contraindications to therapy. 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 62-Year-Old Man Is Brought to the Emergency Department Due