What is the acute management of a 60-year-old female with a one-day history of left-sided body weakness, past medical history of ischemic stroke, hypertension, dyslipidemia, and newly diagnosed atrial fibrillation (AF), presenting with mild drowsiness and grade 2 motor power on the left side, and multiple acute infarcts on CT brain?

Acute Management of Recurrent Ischemic Stroke with Atrial Fibrillation

This 60-year-old woman with multiple acute infarcts, newly diagnosed atrial fibrillation, and prior stroke requires immediate admission to a stroke unit with continuous cardiac monitoring, urgent assessment for reperfusion therapy (though likely outside the window given one-day history), strict blood pressure control avoiding aggressive lowering, DVT prophylaxis with enoxaparin 40 mg daily, and careful planning for anticoagulation initiation after 4-14 days depending on infarct size and hemorrhagic transformation risk. 1, 2

Immediate Stabilization and Monitoring

Airway, Breathing, and Circulation

• Assess and secure airway immediately given her mild drowsiness, as depressed consciousness increases aspiration risk 1, 2
• Provide supplemental oxygen only if hypoxic (oxygen saturation <94%); non-hypoxic patients do not require oxygen therapy 1, 2
• Initiate continuous cardiac monitoring for at least 24-48 hours to detect arrhythmias and confirm atrial fibrillation pattern 2

Neurological Assessment

• Perform validated neurological scale assessment (NIHSS) at baseline and repeat hourly for the first 24 hours to detect early deterioration, which occurs in 25% of stroke patients 2, 1
• Admit to a dedicated stroke unit or neurocritical care unit, as this improves outcomes with strength of evidence level I 1, 2

Blood Pressure Management

Critical pitfall: Avoid aggressive blood pressure lowering, which can reduce cerebral perfusion and expand the infarct. 1, 2

• Do not treat hypertension unless systolic BP >220 mmHg or diastolic BP >120 mmHg, as she is not receiving thrombolytic therapy (outside the window) 1, 2
• If treatment is required, lower blood pressure cautiously by only 15-25% within the first 24 hours 1, 2
• Use easily titratable agents: labetalol or nicardipine (avoid sublingual nifedipine due to precipitous drops) 1, 2

Glucose Management

• Measure serum glucose immediately and correct hypoglycemia urgently 1, 2
• Manage hyperglycemia to keep glucose <300 mg/dL (<16.63 mmol/L), as elevated glucose is associated with poor outcomes 2, 1
• Avoid glucose-containing IV solutions 2

Temperature Control

• Treat sources of fever aggressively and use antipyretics to control elevated temperatures, as hyperthermia worsens outcomes 1, 2

Reperfusion Therapy Assessment

Given the one-day (24-hour) history, she is outside the standard window for IV thrombolysis (3-4.5 hours). 1

• Confirm exact time of symptom onset through detailed history 1
• If any uncertainty exists about timing or if symptoms are fluctuating, urgent vascular imaging (CT angiography or MR angiography) should be performed to assess for large vessel occlusion that might still benefit from mechanical thrombectomy in extended windows 1

DVT Prophylaxis

Start enoxaparin 40 mg subcutaneously once daily for DVT prophylaxis, as this patient is immobilized with severe stroke (grade 2/5 motor power) 2

• This is superior to unfractionated heparin 5000 IU twice daily based on the PREVAIL trial 2
• Alternatively, use intermittent pneumatic compression devices 1
• Early mobilization should begin as soon as safely possible 2

Anticoagulation Strategy for Atrial Fibrillation

This is the most critical decision: timing of anticoagulation initiation in the setting of acute stroke with newly diagnosed AF.

Risk Assessment

• Her CHA₂DS₂-VASc score is ≥4 (age 60 = 1 point, hypertension = 1 point, prior stroke = 2 points, female = 1 point), placing her at very high risk for recurrent stroke 2
• Multiple acute infarcts suggest cardioembolic mechanism from AF 2

Timing of Anticoagulation Initiation

The major concern is hemorrhagic transformation of the acute infarcts, particularly given multiple lesions and cerebellar involvement. 2

• Delay oral anticoagulation for 4-14 days after acute stroke depending on infarct size 2
• For large infarcts (which multiple acute infarcts suggest): wait closer to 14 days 2
• For small to moderate infarcts: may initiate at 4-7 days 2
• Obtain repeat brain imaging (CT or MRI) before starting anticoagulation to exclude hemorrhagic transformation 2

Choice of Anticoagulant

• Direct oral anticoagulants (DOACs) such as rivaroxaban are preferred over warfarin for long-term stroke prevention in non-valvular AF 3
• Rivaroxaban 20 mg once daily (or 15 mg if CrCl 30-50 mL/min) demonstrated non-inferiority to warfarin in the ROCKET AF trial 3
• If warfarin is used, target INR 2.0-3.0 2

Bridging Strategy

• Do not use therapeutic-dose heparin or LMWH for "bridging" in the acute phase, as this increases hemorrhagic transformation risk 2
• Continue prophylactic-dose enoxaparin 40 mg daily for DVT prevention only 2

Aspirin Therapy

Do not start aspirin in the acute phase if planning anticoagulation for AF. 1

• Aspirin 160-300 mg should be started within 48 hours only in patients NOT receiving thrombolysis and NOT requiring anticoagulation 1
• In this patient with AF requiring anticoagulation, aspirin should be avoided to reduce bleeding risk 2

Dysphagia Screening and Aspiration Prevention

• Perform formal dysphagia screening before allowing any oral intake 1
• Keep patient NPO until swallow evaluation is completed 1
• This is critical given her drowsiness and cerebellar involvement affecting coordination 1

Secondary Prevention Measures

Cardiovascular Evaluation

• Obtain baseline ECG and cardiac biomarkers (troponin preferred) to identify concurrent myocardial ischemia 2
• Echocardiogram to assess left atrial size, left ventricular function, and exclude valvular disease 2
• Extended cardiac monitoring (24-48 hour Holter or event recorder) to characterize AF burden 2

Risk Factor Management

• Optimize blood pressure control for secondary prevention (target <140/90 mmHg after acute phase) 2
• Manage dyslipidemia with high-intensity statin therapy 2
• Diabetes screening and management if present 2

Monitoring for Complications

Neurological Deterioration

• One-third of deteriorations occur from stroke progression, one-third from cerebral edema, 10% from hemorrhage, and 11% from recurrent ischemia 2
• Cerebellar infarcts carry particular risk for edema and brainstem compression 2
• Maintain low threshold for repeat imaging if clinical worsening occurs 2

Urinary Tract Infection

• Obtain urinalysis and culture if UTI suspected (fever, altered mental status) 2
• Prescribe appropriate antibiotics if UTI confirmed 2

Key Clinical Pitfalls to Avoid

1. Aggressively lowering blood pressure, which may worsen cerebral perfusion in acute stroke 1, 2
2. Starting therapeutic anticoagulation too early, risking hemorrhagic transformation of multiple acute infarcts 2
3. Using sublingual nifedipine or other agents causing precipitous BP drops 1, 2
4. Delaying imaging or treatment decisions while awaiting non-essential diagnostic tests 1
5. Failing to recognize that 40% of AF patients have intermittent AF not present on initial ECG, requiring extended monitoring 4
6. Overlooking dysphagia screening, leading to aspiration pneumonia 1