What is the management guideline for a 75-year-old male patient presenting with sudden onset of weakness of the right upper and lower limb without facial involvement?

Management of Acute Ischemic Stroke in a 75-Year-Old Male with Right-Sided Hemiparesis

The patient requires immediate emergency evaluation and treatment with intravenous thrombolysis (rtPA) within 4.5 hours of symptom onset, followed by consideration for mechanical thrombectomy if a large vessel occlusion is identified. 1

Initial Emergency Assessment and Management

Immediate Actions (First 10 Minutes)

• Activate stroke code/team
• Establish time of symptom onset (critical for treatment decisions)
• Assess ABCs (Airway, Breathing, Circulation)
• Check vital signs including blood glucose
• Perform rapid neurological examination using NIH Stroke Scale
• Obtain emergent non-contrast CT brain scan to rule out hemorrhage

Urgent Diagnostic Workup (Within 25 Minutes of Arrival)

• Complete brain imaging within 25 minutes of arrival 2
• CT angiography to identify potential large vessel occlusion
• Basic laboratory tests: CBC, coagulation studies, electrolytes, renal function
• ECG to rule out cardiac arrhythmias (particularly atrial fibrillation)

Acute Reperfusion Therapy

Intravenous Thrombolysis

• Administer IV rtPA (0.9 mg/kg, maximum 90 mg) with 10% as bolus and remainder over 60 minutes if:
  • Patient presents within 4.5 hours of symptom onset
  • No contraindications exist (recent surgery, bleeding disorders, etc.)
  • Non-contrast CT shows no hemorrhage or extensive established infarct

Mechanical Thrombectomy Evaluation

• Consider mechanical thrombectomy if:
  • Large vessel occlusion identified on CTA
  • Patient presents within 24 hours of symptom onset
  • Clinical-imaging mismatch suggests salvageable tissue

Medical Management

Immediate Medical Therapy

• Administer systemic anticoagulation with unfractionated heparin unless contraindicated 3
• Maintain euglycemia (treat if glucose <60 mg/dL or >180 mg/dL)
• Control hypertension cautiously:
  • If receiving thrombolysis: Keep BP <180/105 mmHg
  • If not receiving thrombolysis: Treat only if BP >220/120 mmHg
• Maintain normothermia (treat fever >38°C)
• Ensure adequate oxygenation (O₂ saturation >94%)

Early Secondary Prevention

• Initiate antiplatelet therapy (aspirin 325 mg) within 24-48 hours after stroke onset if not receiving thrombolysis
• If receiving thrombolysis, delay antiplatelet therapy for 24 hours
• Begin high-intensity statin therapy

Monitoring and Supportive Care

Neurological Monitoring

• Perform neurological checks every 15 minutes during thrombolysis, then hourly for 24 hours
• Monitor for clinical deterioration suggesting hemorrhagic transformation
• Repeat brain imaging if neurological deterioration occurs

General Supportive Care

• Maintain euvolemia with isotonic fluids
• Elevate head of bed 30° to reduce risk of aspiration
• Initiate dysphagia screening before oral intake
• Begin early mobilization when patient is stable (typically 24 hours post-stroke)

Common Pitfalls to Avoid

1. Delayed Recognition: Stroke is a medical emergency where "time is brain" - every minute delay results in loss of approximately 1.9 million neurons 4

2. Misdiagnosis: Stroke can mimic other conditions like seizures, migraine, or hypoglycemia - perform thorough assessment and appropriate imaging 5

3. Inappropriate Blood Pressure Management: Overly aggressive BP lowering can worsen ischemia; follow guideline-directed BP targets

4. Delayed Transfer: If comprehensive stroke capabilities are not available locally, rapid transfer to a facility with appropriate resources is critical 3

5. Neglecting Comorbidities: Even with successful acute management, stroke patients have high 1-year morbidity and mortality rates; address underlying vascular risk factors 3

By following this evidence-based management approach, you can optimize outcomes for this 75-year-old patient with acute ischemic stroke presenting with right-sided hemiparesis.