In a patient with MRI evidence of multiple acute infarcts in the left cerebellar hemisphere, left thalamus, left capsulo‑ganglionic region, left medial parieto‑temporal lobe, and peri‑trigonal region, who presents with left‑side motor strength 1/5, right‑side spasticity, and aphasia, what is the appropriate acute and secondary stroke management?

Clinical Paradox Suggests Bilateral Hemispheric Involvement or Right-Sided Lesions Not Visualized on Initial MRI

The clinical presentation with left-sided weakness (1/5 power) and aphasia is consistent with the MRI findings of left hemisphere infarcts, but the right-sided spasticity indicates either bilateral involvement, additional right hemisphere lesions not yet apparent on imaging, or a pre-existing right-sided lesion. This discordance requires immediate investigation and aggressive acute stroke management.

Acute Management Algorithm

Immediate Assessment (Within Minutes)

• Time of symptom onset determination - Critical for thrombolytic eligibility 1, 2
• NIHSS score documentation - Guides treatment intensity
• Verify if patient is within treatment window:
  • <4.5 hours from onset: IV alteplase eligible 1, 3
  • 4.5-24 hours: Consider advanced imaging for thrombectomy candidacy 2

Thrombolytic Therapy Decision

Administer IV alteplase (0.9 mg/kg, max 90 mg) if within 4.5 hours and no contraindications 1, 3. The 2018 AHA/ASA guidelines establish this as Class I, Level A evidence for patients presenting within this window 1.

Key contraindications to verify:

• Blood pressure >185/110 mmHg (treat first if elevated) 1
• Glucose <50 or >400 mg/dL (correct first) 1
• INR >1.7 or PT >15 seconds 1
• Recent major surgery/trauma within 14 days 1

Endovascular Thrombectomy Consideration

Obtain CT/CTA or MR angiography immediately to identify large vessel occlusion 2. Given multiple territorial infarcts (left MCA territory, left thalamus, left cerebellar), this suggests:

• Possible basilar or vertebral artery involvement (cerebellar + thalamic)
• Left MCA territory occlusion (capsulo-ganglionic, parieto-temporal)
• Embolic source highly likely - multiple acute infarcts in different vascular territories strongly suggest cardioembolism 4

Thrombectomy window extends to 24 hours for carefully selected patients with favorable imaging 2.

Critical Diagnostic Workup

Explain the Clinical-Radiological Mismatch

The right-sided spasticity with left hemisphere infarcts requires:

1. Repeat MRI brain with DWI immediately - Small acute right hemisphere lesions may have been missed initially 4
2. Review for bilateral lesions - 3% of patients have lesions in both anterior and posterior circulations 4
3. Consider chronic right-sided lesion - Pre-existing stroke or other pathology causing baseline spasticity
4. Assess for evolving infarction - Right hemisphere territory may be actively infarcting

Embolic Source Investigation (High Priority)

Multiple acute infarcts in different territories indicate embolic mechanism 4:

• Transthoracic echocardiogram with bubble study - Look for cardiac thrombus, valvular disease, PFO 5
• Telemetry monitoring minimum 24-48 hours - Detect paroxysmal atrial fibrillation 5
• Consider insertable cardiac monitor if cryptogenic - detects AF in 16% by 6 months vs 3% with standard monitoring 5
• Carotid duplex ultrasound - Assess for high-grade stenosis or ulcerated plaque
• Hypercoagulable workup if age <50 - Yield is low in older patients 5

Acute Physiologic Management

Blood Pressure Control

• Target <185/110 mmHg if thrombolysis planned 1
• Otherwise maintain permissive hypertension <220/120 mmHg for first 24 hours 6

Glucose Management

• Treat hyperglycemia >155 mg/dL 6, 2
• Avoid hypoglycemia <70 mg/dL

Temperature Control

• Treat fever >37.5°C with antipyretics 6

Monitor for Malignant Edema

Given multiple large territory infarcts, risk of herniation is elevated:

• Serial neurological examinations every 2 hours initially
• Consider decompressive hemicraniectomy if malignant cerebral edema develops 6
• ICU-level monitoring warranted

Secondary Prevention Initiation

Antiplatelet Therapy

Do NOT start antiplatelet therapy if thrombolysis administered - wait 24 hours and obtain follow-up imaging to exclude hemorrhagic transformation 1.

Once hemorrhage excluded:

• If high-grade stenosis identified: Consider dual antiplatelet therapy (aspirin + clopidogrel) for 21-90 days
• If cardioembolic source: Anticoagulation preferred over antiplatelets

Anticoagulation Decision

Defer anticoagulation decision until embolic source workup complete:

• If atrial fibrillation confirmed: Start anticoagulation after 4-14 days depending on infarct size
• Larger infarcts require longer delay to reduce hemorrhagic transformation risk

Critical Pitfalls to Avoid

1. Do not dismiss the right-sided spasticity - Assume additional pathology until proven otherwise
2. Do not delay thrombolysis for complete workup - Door-to-needle time should be <60 minutes 1
3. Do not assume single embolic source - Multiple territory infarcts demand comprehensive cardiac evaluation 4
4. Do not start anticoagulation empirically - Wait for source identification and hemorrhage exclusion
5. Do not overlook posterior circulation - Cerebellar and thalamic involvement suggests vertebrobasilar disease

Stroke Unit Care

Admit to dedicated stroke unit - Reduces mortality and improves functional outcomes compared to general ward care 6. Initiate early mobilization and swallow assessment within 24 hours 2.