A 72-year-old woman awoke at 6 am with great difficulty speaking or moving the right side of her body. She arrives in the ED by ambulance at 6:45 am. Her husband corroborates the history and says she was normal last night when she went to sleep. Physical exam shows moderate right-sided weakness and sensory loss and aphasia. Blood pressure is 140/90. Head CT shows signs of an early left middle cerebral artery stroke, no bleeding. Glucose, platelets, and coagulation studies are normal. She has no risk factors for bleeding. It is now 7:30 am. What is the most appropriate treatment at this time?
Thrombolysis
On first glance, this patient may appear to be a good candidate for thrombolysis; however, we do not know whether the stroke occurred within the time window (maximum 4.5 hrs) for thrombolysis—therefore, it should be withheld. In patients with stroke, it is critical to ascertain when they were last normal. This patient was last known to be normal the previous night. She awoke with her deficits, so the stroke could have occurred at any point between the onset of sleep and awakening. Aspirin is the appropriate ED treatment for acute nonhemorrhagic stroke, though if thrombolytics are administered aspirin should be withheld for the first 24 hours. Heparin and other anticoagulants have been shown to be either nonbeneficial or harmful in acute stroke, even in the presence of atrial fibrillation. Nimodipine helps prevent vasospasm in SAH, but antihypertensives are contraindicated in acute ischemic stroke unless the blood pressure is above 220/120 mm Hg, and even then treatment should be very gentle, parenteral, and with close monitoring. Vasopressor therapy to induce hypertension is being studied in acute stroke, but is not standard care at this time.