What is the management plan for a patient with an acute left frontal cortical infarct and probable remote left parietal infarct, diagnosed 16 hours ago on MRI (Magnetic Resonance Imaging) without contrast?

Management of Acute Left Frontal Cortical Infarct (16 Hours Post-Onset)

At 16 hours post-stroke onset, this patient is beyond the window for intravenous thrombolysis (4.5 hours) and likely beyond endovascular thrombectomy eligibility (typically 6-24 hours with strict imaging criteria), so management focuses on immediate admission to a stroke unit, comprehensive diagnostic workup, secondary stroke prevention, and monitoring for complications. 1

Immediate Admission and Monitoring

• Admit directly to a stroke unit or intensive care unit with neuromonitoring capabilities for close observation, as organized stroke unit care significantly reduces death and disability 1, 2
• Perform hourly neurological assessments using the Glasgow Coma Scale for the first 12-24 hours, as changes in GCS within the initial 12 hours predict worse functional outcomes at 90 days 2
• Monitor vital signs routinely including blood pressure, heart rate, oxygen saturation, and temperature 1
• The patient remains at highest risk for neurological deterioration in the first 12-24 hours after infarct onset 2

Urgent Vascular and Cardiac Imaging

• Obtain CT angiography (CTA) of the head and neck from arch-to-vertex immediately to assess for large vessel occlusion, degree of stenosis, and vascular anatomy, as noninvasive intracranial vascular imaging is strongly recommended during initial evaluation 1
• Perform carotid ultrasound/transcranial Doppler as noninvasive imaging of cervicocephalic vessels should be performed routinely to identify stenosis or occlusion 1
• Obtain electrocardiography (ECG) immediately to assess baseline cardiac rhythm and evidence of structural heart disease 1
• Arrange prolonged cardiac monitoring (24-48 hour telemetry minimum, up to 30 days if indicated) to detect paroxysmal atrial fibrillation when cardioembolic mechanism is suspected 1
• Perform echocardiography (at least transthoracic) when cardiac source is suspected, particularly to identify left atrial thrombus, patent foramen ovale, or valvular disease 1

Essential Laboratory Investigations

• Draw blood immediately for: complete blood count with platelets, chemistry panel including electrolytes and creatinine, random glucose, hemoglobin A1C, fasting lipid panel, prothrombin time/INR, and activated partial thromboplastin time 1
• These tests should not delay imaging but are essential for guiding secondary prevention strategies 1

Blood Pressure Management

• Avoid precipitous drops in blood pressure as the ideal blood pressure target in the hyperacute phase is unknown; select pharmacological agents and routes carefully 1
• In patients not receiving thrombolysis (as in this case at 16 hours), permissive hypertension is generally acceptable unless blood pressure is extremely elevated or there are other compelling indications for treatment 1

Seizure Assessment and Management

• Monitor for seizure activity during routine neurological assessments, as seizures can occur at stroke onset or within 24 hours 1
• If a single self-limiting seizure occurs, treat acutely with short-acting medications (e.g., lorazepam IV) but do not initiate long-term anticonvulsant therapy 1
• Do not use prophylactic anticonvulsants, as there is no evidence supporting their use and possible harm with negative effects on neural recovery 1
• Treat recurrent seizures as per standard seizure management protocols 1

Secondary Stroke Prevention Initiation

• Start antiplatelet therapy immediately (aspirin or other appropriate antiplatelet agent based on stroke mechanism once determined) 1
• Initiate statin therapy for hyperlipidemia as part of optimal secondary stroke prevention 1
• Begin blood pressure control measures with appropriate antihypertensive agents once acute phase management is complete 1
• All patients should be discharged with appropriate secondary stroke prevention measures 1

Additional Diagnostic Considerations

• Consider advanced MRI sequences (perfusion, diffusion-weighted imaging) if not already obtained, though this should not delay treatment decisions at this time point 1
• Arrange outpatient follow-up with a neurologist with stroke expertise within 2 weeks to review all test results and optimize secondary prevention strategies 1

Critical Pitfalls to Avoid

• Do not assume the initial MRI shows the full extent of infarction, as up to 25% of initial CT scans can be normal and infarcts evolve over the first 24-48 hours 1, 2
• Do not delay vascular imaging as identification of large vessel occlusion or high-grade stenosis may still influence management decisions regarding anticoagulation, surgical intervention, or transfer to a higher-level center 1
• Do not overlook the remote left parietal infarct, as this indicates recurrent stroke and necessitates aggressive secondary prevention and investigation for underlying etiology 3
• Avoid crossover between unfractionated heparin and low-molecular-weight heparin if anticoagulation is being considered 1