Review Question - QID 217228

This patient presents with dysphagia, right-sided hemianesthesia, and right-sided motor weakness in the setting of a normal non-contrast head CT scan, indicative of an acute ischemic stroke. Since she was last known to be normal 6 hours ago and has a blood pressure > 185/110 mmHg, thus this patient is not a candidate for thrombolytic (alteplase) therapy.

Acute ischemic stroke is caused by acute occlusion of an intracranial blood vessel that presents with neurological deficits depending on the territory affected. Middle cerebral artery strokes can affect the sensory and motor cortices, resulting in contralateral hemianesthesia and hemiplegia. The work-up for stroke includes a non-contrast head CT scan to rule out hemorrhagic stroke and a fingerstick blood glucose test. Patients who present within 4.5 hours of symptom onset (or last known normal) are candidates for intravenous thrombolytic therapy (alteplase) as long as no contraindications exist (history of bleeding, use of anticoagulation, poorly controlled hypertension > 180/110 mmHg, internal bleeding, recent head trauma, coagulopathy). For patients who present between 4.5 and 24 hours of symptom onset, a CT or magnetic resonance (MR) angiogram is performed; if a large artery occlusion is identified in either the anterior or posterior circulations, then the patient may be a candidate for mechanical thrombectomy depending on the exact timing of symptoms.

Powers et al. outline the guidelines for acute ischemic stroke management. They discuss that intravenous thrombolytic therapy is recommended for patients presenting within 4.5 hours of symptom onset with no contraindications. They recommend using a coordinated system of care for stroke management including secondary prevention measures for further strokes such as blood pressure control.

Incorrect Answers:
Answer 2: Aspirin is incorrect because it is an anti-platelet agent that is indicated within 48 hours of symptom onset for the prevention of recurrent stroke. It is appropriate in patients with ischemic strokes who are not thrombolytic candidates. Long-term, patients with an ischemic stroke are typically on aspirin for secondary stroke prevention.

Answers 3 & 4: Labetalol and nicardipine are anti-hypertensive agents that are indicated in the management of severe hypertension in patients with acute ischemic stroke. Blood pressure targets for patients with acute ischemic stroke who are not candidates for thrombolytic therapy is <= 220/120 mmHg. For patients undergoing thrombolytic therapy, the target is <= 185/110 mmHg. If a patient's hypertension can be controlled and the patient is within the thrombolytic window, thrombolytics can be given.

Answer 5: Rosuvastatin is a lipid-lowering statin that is indicated in suspected atherosclerotic stroke when patients have a LDL cholesterol >= 70 mg/dL. It works to prevent recurrent stroke. Side effects include lactic acidosis and myositis.

Bullet Summary:
Thrombolytic therapy is indicated in acute ischemic strokes if symptom onset is < 4.5 hours and no contraindications exist.