Review Question - QID 215067

This patient is presenting with sudden onset focal neurologic deficits (right upper extremity weakness, right finger-nose abnormality, facial droop, right lower extremity weakness, and inability to write or use utensils), and a CT scan without evidence of intracranial hemorrhage, all of which suggests an ischemic stroke. Given his history of intracranial hemorrhage, he is not a tissue plasminogen activator candidate and thus can be managed medically with aspirin and atorvastatin.

Acute ischemic strokes are common in elderly patients with risk factors such as diabetes, hypertension, dyslipidemia, and atrial fibrillation. Acute ischemic strokes classically present with sudden onset, focal neurologic deficits. A quick exam should be performed to support a diagnosis of stroke followed by an immediate CT scan of the head to rule out intracranial hemorrhage. If the patient is a tissue plasminogen activator candidate, then it should be promptly administered as early administration in ischemic stroke may be associated with better outcomes. However, if the patient is not a tissue plasminogen activator candidate, then medical management is indicated. Medical management involves aspirin and statins with a goal LDL < 70 mg/dL. Other steps in medical management include treating hypertension, tight glycemic control, smoking cessation, and treating any other comorbidities or risk factors for stroke. Magnetic resonance imaging (MRI) to characterize the stroke, an echocardiogram, and carotid imaging may also be performed non-urgently. It is important to note that a mechanical thrombectomy is an alternative option for patients with large vessel occlusion whether or not they receive tissue plasminogen activator.

Albers et al. studied the role of mechanical thrombectomy in patients at 6 to 16 hours after they were last known to be well. Among 182 patients with a proximal middle-cerebral-artery or internal-carotid-artery occlusion who had remaining ischemic brain tissue not yet infarcted, endovascular therapy improved functional outcomes on the modified Rankin scale at 90 days (odds ratio 2.77). The authors recommend the use of endovascular thrombectomy for ischemic stroke up to 16 hours after the last known well time in appropriately selected patients.

Figure/Illustration A is a normal head CT without mass, bleed, or midline shift which in the setting of this patient's focal neurologic deficits supports a diagnosis of an ischemic stroke. Normal calcification of the choroid plexus is highlighted with blue circles.

Incorrect Answers:
Answer 1: Alteplase is the appropriate management of an acute ischemic stroke (with an intracranial hemorrhage ruled out on a CT scan of the head) if the patient presents within 4.5 hours and has no contraindications to tissue plasminogen activator. This patient's history of intracranial hemorrhage (subdural hemorrhage) is a contraindication to tissue plasminogen activator.

Answer 3: Mannitol is an osmotic agent that can be used to reduce intracranial pressure when there is a concern for increased intracranial pressure, such as after head trauma that results in diffuse axonal injury. Diffuse axonal injury leads to blurring of the gray-white matter interface and devastating neurological injury. Increased intracranial pressure is common in this condition, and other measures to lower pressure could include elevating the head of the bed or hypertonic saline.

Answer 4: Prothrombin complex concentrate could be used to reverse anticoagulation from warfarin. If this patient had an intracranial bleed and were on warfarin, then prothrombin complex concentrate would be indicated. If this is not available, fresh frozen plasma can be used. Finally, vitamin K can be used to reverse warfarin; however, it works slowly and thus is not appropriate for someone who is acutely bleeding.

Answer 5: Surgical resection would be appropriate management of an intracranial mass that presents with headaches. Ataxia is also a possible presentation, and depending on the lesion and location, neurosurgical resection may be indicated.

Bullet Summary:
Acute ischemic strokes in patients who are not tissue plasminogen activator candidates can be managed medically with aspirin and statins.