What is the most appropriate next step in managing a 77-year-old female with sudden-onset dysarthria, slurred speech, and facial hemiplegia, within 3 hours of symptom onset, with a negative head computed tomography (CT) scan and normal coagulation studies?

Management of Acute Ischemic Stroke with Sudden-Onset Neurological Symptoms

Intravenous alteplase (0.9 mg/kg, maximum dose 90 mg) is the most appropriate next step in management for this 77-year-old female presenting with sudden-onset dysarthria, slurred speech, and facial hemiplegia within 1.5 hours of symptom onset, with a negative head CT and normal coagulation studies.

Patient Assessment and Eligibility for IV Alteplase

This patient presents with classic symptoms of acute ischemic stroke:

• Sudden-onset dysarthria, slurred speech, and facial hemiplegia
• Symptom onset 1.5 hours ago (well within the treatment window)
• Negative head CT (ruling out hemorrhagic stroke)
• Normal coagulation studies
• No absolute contraindications identified

Key Eligibility Factors Supporting IV Alteplase:

• Time from symptom onset is 1.5 hours (within the 0-3 hour window where benefit is greatest)
• Neurological deficits are potentially disabling
• No evidence of intracranial hemorrhage on imaging
• Normal coagulation studies
• Blood pressure is 152/74 mmHg (below the threshold of 185/110 mmHg)

Evidence-Based Rationale

The American Heart Association/American Stroke Association guidelines strongly recommend IV alteplase for patients who can be treated within 3 hours of symptom onset 1. The benefit of IV alteplase is well-established for adult patients with disabling stroke symptoms regardless of age and stroke severity when administered within this time window.

The efficacy of IV alteplase is time-dependent, with earlier treatment associated with better outcomes 2. Treatment within 3 hours results in approximately 33% of patients achieving good outcomes compared to 23% with placebo (OR 1.75,95% CI 1.35-2.27) 2.

Administration Protocol

1. Administer IV alteplase 0.9 mg/kg (maximum dose 90 mg)

   • 10% as initial bolus over 1 minute
   • Remaining 90% as continuous infusion over 60 minutes

2. Post-administration monitoring:

   • Neurological checks every 15 minutes for the first 2 hours
   • Blood pressure monitoring with target <180/105 mmHg
   • Monitor for signs of intracranial hemorrhage

Why Other Options Are Not Appropriate

• Aspirin 325 mg (Option A): While aspirin is beneficial for patients not eligible for thrombolysis, it is not the optimal initial treatment for a patient presenting within the thrombolysis window 1. Aspirin should be delayed until 24 hours after IV alteplase administration.

• IV nicardipine infusion (Option B): While blood pressure management is important, this patient's BP is already below the threshold requiring aggressive treatment prior to thrombolysis. Treating the stroke with IV alteplase takes priority.

• Therapeutic fondaparinux (Option C): Anticoagulation with heparin or fondaparinux is not recommended as first-line therapy for acute ischemic stroke 3.

• Dabigatran (Option E): Direct oral anticoagulants are not indicated for acute stroke treatment but may be considered later for secondary prevention in specific cases.

Special Considerations for This Patient

Age Consideration

Despite the patient's age (77 years), advanced age is not a contraindication for IV alteplase within the 0-3 hour window 1, 3. The benefits of treatment outweigh the risks even in elderly patients when treated within 3 hours.

Comorbidities

The patient's history of hypertension, diabetes, and coronary artery disease increases her stroke risk but does not contraindicate IV alteplase. These comorbidities should be managed as part of her comprehensive care after the acute treatment.

Potential Complications and Management

The main risk of IV alteplase is symptomatic intracranial hemorrhage (approximately 2.4% of treated patients) 3. If hemorrhagic conversion occurs:

• Stop the infusion immediately
• Obtain emergent neurosurgical consultation
• Consider cryoprecipitate or fresh frozen plasma
• Manage blood pressure aggressively

Conclusion

Based on the patient's presentation with acute stroke symptoms within 1.5 hours, negative head CT, and no contraindications, IV alteplase (Option D) represents the standard of care with the greatest potential benefit for reducing disability and improving functional outcomes.