What is the most appropriate initial medication for a patient with suspected acute stroke, presenting with sudden onset unilateral weakness and decreased level of consciousness?

Management of Acute Stroke with Unilateral Weakness and Decreased Consciousness

For a patient with suspected acute ischemic stroke presenting with sudden onset unilateral weakness and decreased level of consciousness, thrombolytic therapy (option C) is the most appropriate initial medication.

Initial Assessment and Management

Rapid Evaluation

• Immediate neuroimaging with non-contrast CT brain to rule out hemorrhage 1
• Vascular imaging (CTA or MRA from arch to vertex) should be completed without delay 1
• ECG should be performed but should not delay assessment for thrombolysis 1

Time-Critical Decision Making

• Time from symptom onset is the most critical factor in determining treatment eligibility
• For patients within 3 hours of symptom onset, IV thrombolysis with recombinant tissue plasminogen activator (r-tPA) is strongly recommended (Grade 1A) 1
• For patients between 3-4.5 hours of symptom onset, IV r-tPA is still suggested (Grade 2C) 1
• After 4.5 hours, IV r-tPA is not recommended (Grade 1B) 1

Treatment Algorithm

If Within 4.5 Hours of Symptom Onset:

1. Administer IV thrombolytic therapy (r-tPA) at 0.9 mg/kg (maximum 90 mg) with 10% given as bolus over 1 minute and remainder over 59 minutes 1, 2
2. Monitor blood pressure closely - maintain <185/110 mmHg before treatment and <180/105 mmHg for 24 hours after 2
3. Monitor neurological status frequently using standardized stroke scales 2

If Beyond 4.5 Hours or Contraindications to Thrombolysis:

1. Administer aspirin 160-325 mg within 48 hours of stroke onset 1, 2
2. Consider endovascular therapy if large vessel occlusion is identified and patient presents within appropriate timeframe 1, 2

Rationale for Thrombolytic Therapy

Thrombolytic therapy is the only FDA-approved treatment for acute ischemic stroke that has been shown to significantly improve outcomes 3. The American College of Chest Physicians guidelines strongly recommend IV r-tPA for patients presenting within 3 hours of symptom onset (Grade 1A evidence) 1.

The patient's presentation with:

• Sudden onset weakness affecting half the body
• Decreased level of consciousness (couldn't be awakened)
• History of diabetes and hypertension (common stroke risk factors)

Strongly suggests an acute ischemic stroke, which requires urgent reperfusion therapy.

Why Not Other Options?

Aspirin (Option B)

• While aspirin is recommended within 48 hours of ischemic stroke onset (Grade 1A) 1, it is not the first-line treatment for acute stroke when thrombolysis is an option
• Aspirin provides only modest benefit compared to thrombolysis in acute stroke 1
• Aspirin should be withheld for 24 hours after thrombolytic therapy 1

Clopidogrel (Option A)

• Not recommended as initial therapy for acute stroke
• More appropriate for long-term secondary prevention after the acute phase 1
• Guidelines suggest clopidogrel for long-term secondary prevention (Grade 2B) but not for initial management 1

Important Considerations and Pitfalls

• Critical Time Window: Delay in treatment dramatically reduces effectiveness - "time is brain" 4, 5
• Hemorrhage Risk: Thrombolysis carries risk of intracerebral hemorrhage (approximately 3-6%) 4
• Contraindications: Recent major surgery, active bleeding, history of intracranial hemorrhage, or uncontrolled hypertension are contraindications to thrombolysis 1
• Blood Pressure Management: Hypertension must be controlled before and after thrombolysis to reduce hemorrhage risk 2
• Swallowing Assessment: Should be performed but should not delay thrombolytic therapy 1

Post-Thrombolysis Care

• Transfer to stroke unit or ICU for specialized care and monitoring 2
• Implement DVT prophylaxis with intermittent pneumatic compression devices 2
• Monitor for and treat complications, particularly hemorrhagic transformation 6
• Maintain normothermia; treat fever aggressively 2
• Begin secondary prevention measures after acute phase stabilization 2

The evidence clearly supports thrombolytic therapy as the most appropriate initial treatment for this patient with suspected acute ischemic stroke presenting with unilateral weakness and decreased consciousness, assuming they are within the appropriate time window and have no contraindications.