What is the next step for a stroke patient within the 4-hour window, with a computed tomography (CT) brain scan negative for ischemia/hemorrhage, normal laboratory results except for hyperglycemia (elevated blood glucose), and hypertension (elevated blood pressure)?

From the Guidelines

For a stroke patient within the 4-hour window with a negative CT brain scan and normal labs except for mild hyperglycemia (blood glucose 6 mmol/L) and hypertension (BP 180/100), the next step is to administer intravenous tissue plasminogen activator (tPA, alteplase) at a dose of 0.9 mg/kg with a maximum of 90 mg (10% as bolus, remainder over 60 minutes). Before administration, blood pressure should be lowered to <185/110 mmHg using labetalol 10-20 mg IV or nicardipine 5 mg/hour IV, titrated as needed, as recommended by the most recent guidelines 1. The patient should be monitored in an intensive care setting with neurological assessments every 15 minutes during infusion, then hourly for 24 hours. Blood pressure should be maintained <180/105 mmHg for 24 hours post-treatment. Antiplatelet or anticoagulant therapy should be withheld for 24 hours after tPA. This treatment is recommended because the patient is within the therapeutic window for thrombolysis, has clinical signs of stroke with no contraindications on imaging, and the benefits of restoring blood flow outweigh the risks of hemorrhagic transformation. The mild hyperglycemia should be monitored but doesn't contraindicate treatment, while the hypertension needs control before and during therapy to reduce bleeding risk, as supported by previous studies 1.

Some key points to consider in the management of this patient include:

• The importance of prompt administration of tPA within the therapeutic window, as emphasized in the guidelines 1
• The need for careful blood pressure management before, during, and after tPA administration, as highlighted in the guidelines 1 and supported by previous studies 1
• The monitoring of hyperglycemia, although it does not contraindicate tPA treatment, as noted in previous research 1
• The withholding of antiplatelet or anticoagulant therapy for 24 hours after tPA, as recommended in the guidelines 1 and supported by previous studies 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Next Steps for Stroke Patient

Given the patient's condition, with a CT brain negative for ischemia/hemorrhage and normal labs except for blood glucose 6 and BP 180/100, within the 4-hour window, the next steps can be considered as follows:

• The patient is a potential candidate for thrombolysis, as the CT brain is negative for ischemia/hemorrhage 2, 3.
• The elevated blood pressure (BP 180/100) should be managed according to guidelines, as high blood pressure can increase the risk of intracerebral hemorrhage after thrombolysis 2.
• The blood glucose level of 6 is not significantly elevated and may not require immediate intervention, but monitoring is necessary to ensure it does not impact the patient's condition or treatment outcomes.
• Consideration of the patient's eligibility for thrombectomy, if applicable, should be based on the latest guidelines and the patient's specific condition, including the location and severity of the stroke 4.
• The decision to proceed with thrombolysis or thrombectomy should be made by a multidisciplinary team, taking into account the patient's overall condition, the time from symptom onset, and the potential risks and benefits of each treatment option 2, 3, 5, 4.

Treatment Options

The treatment options for the patient can include:

• Intravenous thrombolysis with alteplase, which is the only approved medical treatment for patients with acute ischemic stroke, if the patient meets the eligibility criteria 2, 3.
• Mechanical thrombectomy, which can be considered for patients with proximal occlusions of the cerebral arteries, especially if the patient has a large vessel occlusion 4.
• Management of the patient's blood pressure and blood glucose levels to minimize the risk of complications and improve outcomes.

Time Window Considerations

The 4-hour window for treatment is critical, and the decision to proceed with thrombolysis or thrombectomy should be made promptly, taking into account the patient's condition and the potential risks and benefits of each treatment option 6, 5.