What is the initial management for a patient with a Corona radiata (tissue plasminogen activator (tPA) eligible) stroke?

Initial Management of Corona Radiata Stroke (tPA Eligible)

For patients with corona radiata stroke who are eligible for tissue plasminogen activator (tPA), immediate administration of intravenous alteplase (0.9 mg/kg, maximum dose 90 mg) is recommended within 4.5 hours of symptom onset, with earlier treatment associated with better outcomes.

Immediate Assessment and Triage

• Assign high-severity triage category to be seen within 10 minutes of ED arrival 1
• Activate "Code Stroke" protocol to expedite evaluation and treatment 1
• Perform rapid assessment of:
  • Airway, breathing, circulation
  • Neurological status using NIHSS (National Institutes of Health Stroke Scale) 1
  • Vital signs (heart rate, rhythm, blood pressure, temperature, oxygen saturation) 2

Urgent Diagnostic Evaluation

• Obtain immediate non-contrast CT scan of the brain within 25 minutes of arrival 1
  • CT should be interpreted within 45 minutes of arrival 1
  • Primary purpose: rule out hemorrhage and identify early signs of infarction
• Essential laboratory tests:
  • Complete blood count with platelets
  • Electrolytes and renal function
  • Coagulation studies
  • Blood glucose
  • Troponin 2
• 12-lead ECG to identify atrial fibrillation or evidence of structural heart disease 2

tPA Administration Protocol

1. Eligibility assessment:

   • Confirm diagnosis of ischemic stroke with measurable neurologic deficit
   • Verify symptom onset is within 4.5 hours
   • Review contraindications (see below)
   • Ensure blood pressure is <185/110 mmHg 1

2. tPA dosing and administration:

   • Administer 0.9 mg/kg (maximum dose 90 mg)
   • Give 10% as initial bolus over 1 minute
   • Infuse remaining 90% over 60 minutes 1

3. Blood pressure management:

   • Before tPA: maintain BP <185/110 mmHg
   • During and after tPA: maintain BP <180/105 mmHg for at least 24 hours
   • Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1
   • For elevated BP:
     • Labetalol 10-20 mg IV over 1-2 minutes (may repeat once), or
     • Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5-15 minutes (maximum 15 mg/hr) 1

Key Contraindications to tPA

• Head trauma or prior stroke in previous 3 months
• Symptoms suggesting subarachnoid hemorrhage
• Arterial puncture at noncompressible site in previous 7 days
• History of previous intracranial hemorrhage
• Elevated blood pressure (systolic >185 mmHg or diastolic >110 mmHg)
• Evidence of active bleeding
• Acute bleeding diathesis
• Blood glucose <50 mg/dL
• CT showing multilobar infarction (hypodensity >1/3 cerebral hemisphere) 1

Post-tPA Management

• Position patient in semi-recumbent position to prevent aspiration 2
• Avoid antiplatelet or anticoagulant medications for 24 hours after tPA administration 2
• Continue neurological monitoring with serial examinations to detect early deterioration 2
• Monitor for complications:
  • Symptomatic intracerebral hemorrhage (sICH): Rates approximately 4.3-7.8% 3
  • Angioedema
  • Systemic bleeding

Time Considerations

• Earlier treatment with tPA is associated with better outcomes 1
• Treatment window:
  • 0-3 hours: strongest evidence for benefit
  • 3-4.5 hours: still beneficial but with slightly higher risk of complications 3
  • Beyond 4.5 hours: not recommended as standard care 4

Subsequent Management

• Transfer to dedicated stroke unit for multidisciplinary care 2
• Initiate early mobilization when hemodynamically stable 2
• Begin rehabilitation within 24-48 hours for stable patients 2
• Start secondary stroke prevention measures based on stroke etiology 2

Special Considerations for Corona Radiata Strokes

• Corona radiata strokes may have significant impact on motor function, particularly affecting finger extensors 5
• Recovery may continue over an extended period (months to years) 5
• Early rehabilitation is crucial for maximizing functional recovery 2

Remember that the time window for tPA administration is critical - "time is brain" - and every effort should be made to minimize door-to-needle time, with a goal of less than 60 minutes from hospital arrival to tPA administration.