What is the management for an elderly man presenting 2 hours after onset of symptoms with a non-hemorrhagic stroke, with a history of non-hemorrhagic stroke 2 months ago, and a CT scan confirming non-hemorrhagic stroke?

Management of Acute Ischemic Stroke in an Elderly Man Presenting at 2 Hours

For an elderly man presenting 2 hours after onset of a non-hemorrhagic stroke with history of non-hemorrhagic stroke 2 months ago, thrombolysis with intravenous alteplase (tPA) is the recommended management option (answer B).

Rationale for Thrombolysis

• The patient presents within the established 3-hour window for intravenous thrombolysis, which is supported by high-quality evidence 1, 2
• CT scan confirms a non-hemorrhagic stroke, which is a prerequisite for thrombolysis 1
• The American Heart Association/American Stroke Association guidelines strongly recommend IV alteplase (0.9 mg/kg, maximum dose 90 mg) for patients who can be treated within 3 hours of symptom onset 1
• Time is critical - earlier treatment leads to better outcomes, with a clear time-dependent effect on efficacy 2

Previous Stroke History Consideration

• A history of ischemic stroke more than 3 months ago is not a contraindication for thrombolysis 1
• However, this patient had a stroke 2 months ago, which requires careful consideration
• The guidelines do not explicitly list a recent ischemic stroke (within 3 months) as an absolute contraindication, but rather as a relative consideration 1
• The potential benefit of improved functional outcomes with thrombolysis outweighs the risks in this time-sensitive situation 1

Implementation Protocol

1. Immediate administration of IV alteplase:

   • Dose: 0.9 mg/kg (maximum 90 mg)
   • Administration: 10% as bolus over 1 minute, remaining 90% as infusion over 60 minutes 1

2. Blood pressure management:

   • Ensure BP <185/110 mmHg before thrombolysis
   • Maintain BP <180/105 mmHg after treatment 1, 2

3. Monitoring:

   • Close neurological monitoring every 15 minutes for the first 2 hours 2
   • Monitor for signs of intracranial hemorrhage or other complications

Why Other Options Are Not Appropriate

• PCI (Option A): Percutaneous coronary intervention is not indicated for ischemic stroke management
• Heparin (Option C): Not recommended as first-line therapy for acute ischemic stroke 1
• Aspirin (Option D): While beneficial for secondary prevention, aspirin alone is not the optimal initial treatment for a patient presenting within the thrombolysis window 1

Important Considerations

• Hemorrhagic risk: Monitor for symptomatic intracranial hemorrhage, which occurs in approximately 2.4% of patients treated with alteplase 3
• Contraindications: Ensure no absolute contraindications such as active bleeding, recent major surgery, or blood glucose abnormalities 1
• Efficacy: IV alteplase significantly improves functional outcomes when administered within the appropriate time window, with benefits outweighing risks for eligible patients 1

The 2-hour time window in this case represents an optimal opportunity for thrombolytic therapy, which has been proven to reduce disability and improve functional outcomes in acute ischemic stroke patients.