Management of Acute Ischemic Stroke with Focal Neurological Deficits
Intravenous alteplase (tPA) is the most appropriate next step in managing this 76-year-old male with acute onset of focal neurological deficits presenting within the treatment window.
Clinical Assessment and Indication for Thrombolysis
This patient presents with classic signs of acute ischemic stroke:
- Acute onset of focal neurological deficits (slurred speech, left-sided motor deficits, facial droop)
- Symptoms began 2 hours ago (well within the treatment window)
- Non-contrast CT scan has ruled out hemorrhagic stroke
The patient meets criteria for IV alteplase administration based on:
- Presentation within the 3-hour treatment window (symptoms began 2 hours ago) 1
- Measurable neurological deficit (left-sided motor deficits, facial droop, slurred speech)
- No evidence of hemorrhage on non-contrast CT scan
Blood Pressure Management Prior to Thrombolysis
The patient's blood pressure is 205/100 mmHg, which exceeds the threshold for safe administration of alteplase. According to AHA guidelines, blood pressure must be controlled to <185/110 mmHg before alteplase administration 1.
Blood pressure management protocol:
- Reduce blood pressure to <185/110 mmHg before administering alteplase
- Use IV labetalol 10 mg followed by continuous IV infusion 2-8 mg/min, or
- Nicardipine IV 5 mg/h, titrated up by 2.5 mg/hr every 5-15 minutes to maximum 15 mg/h 1
Contraindications Assessment
The patient does not have any clear contraindications to thrombolytic therapy:
- No evidence of intracranial hemorrhage on CT scan
- No recent history of trauma, surgery, or prior stroke mentioned
- No evidence of bleeding diathesis
- No mention of anticoagulant use (he is on HCTZ, metformin, and semaglutide)
Post-Thrombolysis Monitoring
After administering alteplase, the following monitoring is required:
- Blood pressure checks every 15 minutes for 2 hours
- Then every 30 minutes for 6 hours
- Then hourly for 16 hours 1
- Maintain blood pressure <180/105 mmHg to reduce risk of intracerebral hemorrhage 1
Why Other Options Are Not Appropriate
Decompressive craniectomy (Option A): Not indicated in the acute phase for this patient as there is no evidence of large territorial infarction with mass effect or malignant cerebral edema.
Intravenous esmolol (Option B): While blood pressure control is needed, esmolol is not the recommended first-line agent. Guidelines specifically recommend labetalol or nicardipine for pre-thrombolysis blood pressure management 1.
Intravenous prothrombin complex concentrate (Option C): This would be indicated for reversal of anticoagulation in hemorrhagic stroke, not for ischemic stroke. The CT scan has ruled out hemorrhage.
Therapeutic low-molecular-weight heparin (Option D): Not recommended in the acute phase of ischemic stroke management. Anticoagulation is not a first-line treatment for acute ischemic stroke and may increase bleeding risk if given with or shortly after thrombolysis.
Important Considerations and Pitfalls
- Time is brain: Every minute delay in treatment results in loss of approximately 2 million neurons 1
- Blood glucose: Ensure blood glucose is not <50 mg/dL before administering alteplase 1
- Rapid deterioration: If neurological status worsens after thrombolysis, obtain immediate CT scan to rule out hemorrhagic transformation
- Avoid delays: CT scan should ideally be completed within 25 minutes of arrival and interpreted within 45 minutes 1
- Advanced imaging: While CT perfusion or CT angiography may be considered, these should not delay administration of IV alteplase in eligible patients 1
By following this evidence-based approach, the patient has the best chance of neurological recovery with minimized risk of complications.