What is the management plan for a 52-year-old female presenting to the ER with acute onset left-sided weakness, dizziness, and speech issues, suggestive of a stroke, with a history of similar episodes and current medications including aspirin (acetylsalicylic acid), atorvastatin (LIPITOR), glipizide (GLUCOTROL), metformin (GLUCOPHAGE), nifedipine (PROCARDIA), and olmesartan (BENICAR)?

Inpatient Management of Acute Ischemic Stroke Post-Thrombolysis

One-Liner

52-year-old female with acute left-sided weakness, dysarthria, and dizziness presenting 8:45 AM, received TNK for acute ischemic stroke, now admitted for stroke unit care and secondary prevention.

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Subjective

Chief Complaint: Acute onset left-sided weakness, dizziness, and speech difficulties while driving at 8:45 AM

History of Present Illness:

• Sudden onset left arm and leg weakness with associated dizziness and dysarthria at 8:45 AM 1
• Similar episode in September (possible prior stroke) with complete resolution 2
• Current symptoms worse than prior episode 1
• Mild head pressure, no headache, no vision changes, no recent trauma 3

Past Medical History:

• Prior possible stroke (September) 2
• Diabetes mellitus (on glipizide, metformin) 3
• Hypertension (on nifedipine, olmesartan, olmesartan-HCTZ) 3
• Hyperlipidemia (on atorvastatin) 3

Current Medications:

• Aspirin 81 mg daily 3
• Atorvastatin 10 mg nightly 4
• Glipizide 10 mg BID 3
• Metformin XR 1000 mg daily 3
• Nifedipine XL 30 mg daily 3
• Olmesartan 5 mg daily 3
• Olmesartan-HCTZ 40-25 mg daily 3
• Famotidine 10 mg PRN 3

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Initial ED Workup & Imaging

Vital Signs: Stable, blood pressure adequately controlled 3

Neurological Examination:

• Left-sided weakness 1
• Left-sided altered sensation/numbness 1
• Dysarthria 1
• Awake and alert 3

Imaging:

• CT Head (non-contrast): Negative for hemorrhage 1
• CT Perfusion: No evidence of diminished cerebral blood flow or elevated transit time suggesting large territorial infarct 1
• CTA Head/Neck: No aneurysm, occlusion, or hemodynamically significant stenosis; no large vessel occlusion (LVO) 1

Laboratory Studies:

• Mild hypokalemia 1
• Otherwise unrevealing 1
• (Assume: CBC, electrolytes, renal function, glucose, coagulation studies, troponin completed per protocol) 3

ED Treatment:

• TNK (tenecteplase) administered after negative CT 1
• Patient remained stable post-thrombolysis 1

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Assessment

Primary Diagnosis: Acute ischemic stroke, likely cardioembolic or small vessel disease given history of diabetes and hypertension, with recurrent stroke pattern 2

Differential Diagnosis:

1. Cardioembolic stroke - requires cardiac monitoring for atrial fibrillation 5
2. Small vessel (lacunar) stroke - given diabetes and hypertension 2
3. Large artery atherosclerosis - less likely given negative CTA 2
4. Cryptogenic stroke - requires further workup 2

Risk Stratification: High risk for recurrent stroke given prior event in September; estimated 7.5-17.4% risk of stroke in next 3 months post-TIA/minor stroke 2

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Inpatient Management Plan

Immediate Post-Thrombolysis Care (First 24 Hours)

Blood Pressure Management:

• Maintain BP <180/105 mmHg for at least 24 hours post-thrombolysis 3, 1
• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 3
• If SBP 180-230 mmHg or DBP 105-120 mmHg: use labetalol 10 mg IV followed by continuous infusion 2-8 mg/min, or nicardipine 5 mg/h IV titrated up by 2.5 mg/h every 5-15 minutes (max 15 mg/h) 3
• Hold home antihypertensives for first 24 hours to avoid unpredictable responses during acute stress 3

Neurological Monitoring:

• Perform neurological assessments using NIHSS every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 3
• Watch for hemorrhagic transformation, cerebral edema (peaks 3-5 days but can occur earlier), and seizures 5
• Urgent repeat CT if neurological deterioration occurs 3

NPO Status & Swallowing:

• Keep patient NPO until formal swallowing screen completed 3
• Swallowing screen should be performed on day of admission using validated tool 3
• If abnormal screen, refer to speech-language pathologist for detailed assessment 3
• Prevents aspiration pneumonia, a major complication 5

Antiplatelet Therapy:

• Do NOT give aspirin for 24 hours post-thrombolysis 3, 1
• After 24 hours, initiate aspirin 160-300 mg daily 3, 1

Correct Hypokalemia:

• Replete potassium to >4.0 mEq/L 3
• Monitor electrolytes daily 3

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Stroke Unit Care (Days 1-7)

Admit to Stroke Unit:

• All acute ischemic stroke patients should receive comprehensive stroke unit care 5
• Stroke unit care reduces mortality and improves functional outcomes 3

Cardiac Monitoring:

• Continuous cardiac monitoring for at least 24-48 hours to detect atrial fibrillation and arrhythmias 3, 5
• Obtain baseline ECG (already done in ED) 3
• If atrial fibrillation detected, will require anticoagulation after ruling out hemorrhagic transformation 5

Temperature Management:

• Monitor temperature every 4 hours for first 48 hours 3
• If temperature >37.5°C (99.5°F): increase monitoring frequency, initiate cooling measures, investigate for infection (pneumonia, UTI), and treat with antipyretics and antimicrobials as needed 3

Venous Thromboembolism Prophylaxis:

• Initiate subcutaneous heparin 5000 units BID or enoxaparin 40 mg daily for DVT prophylaxis 3, 5
• Combine with intermittent pneumatic compression devices 3
• Early mobilization and adequate hydration 3
• Anti-embolism stockings alone are NOT recommended 3

Early Mobilization:

• Begin frequent, brief out-of-bed activity within 24 hours if no contraindications (sitting, standing, walking) 3
• Initial rehabilitation assessment by physical therapy, occupational therapy, and speech therapy within 48 hours 3
• Active rehabilitation should begin as soon as patient is medically stable 3

Nutrition & Hydration:

• If swallowing screen abnormal, consider nasogastric or nasoduodenal tube feeding 5
• Maintain adequate hydration to prevent DVT 3
• Dietitian consultation for nutritional assessment 3

Seizure Monitoring:

• Monitor for seizures during routine vital signs and neurological checks 3
• If single self-limiting seizure occurs, do NOT start long-term anticonvulsants 3
• If recurrent seizures, treat with short-acting medication (lorazepam IV) and consider long-term anticonvulsant therapy 3
• Prophylactic anticonvulsants are NOT recommended and may harm neurological recovery 3

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Secondary Prevention Workup (Days 1-3)

Cardiac Evaluation:

• Extended cardiac monitoring (minimum 24-48 hours, ideally longer) to detect paroxysmal atrial fibrillation 5
• Echocardiogram (transthoracic, consider transesophageal if high suspicion for cardioembolic source) to evaluate for thrombus, valvular disease, patent foramen ovale 5
• Troponin monitoring (already obtained in ED) 3

Vascular Imaging:

• CTA head/neck already completed showing no significant stenosis 1
• No need for carotid revascularization given absence of stenosis 2

Additional Laboratory Studies:

• Fasting lipid panel (patient already on statin but need baseline) 4
• Hemoglobin A1c for diabetes control 3
• Consider hypercoagulable workup if cryptogenic stroke in young patient (not applicable here given age and risk factors) 2

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Long-Term Secondary Prevention (Initiate During Hospitalization)

Antiplatelet Therapy:

For this patient with minor-to-moderate stroke and no atrial fibrillation detected:

• After 24 hours post-thrombolysis, initiate dual antiplatelet therapy with aspirin 81 mg + clopidogrel 75 mg daily for 21 days 2, 6
• This reduces stroke risk from 7.8% to 5.2% (HR 0.66) in high-risk TIA/minor stroke patients 2
• After 21 days, transition to single antiplatelet therapy (clopidogrel 75 mg daily OR aspirin 81 mg daily) 3, 6
• Clopidogrel or aspirin/extended-release dipyridamole preferred over aspirin alone for long-term secondary prevention 3
• Do NOT continue dual antiplatelet therapy beyond 21 days due to increased bleeding risk without additional benefit 6, 4

If atrial fibrillation is detected:

• Anticoagulation is superior to antiplatelet therapy 3
• Initiate oral anticoagulation (apixaban, rivaroxaban, or warfarin) after ruling out hemorrhagic transformation on repeat imaging 3, 5
• Typically start anticoagulation 1-2 weeks after stroke onset; earlier for small infarcts, later for large infarcts 3
• Discontinue antiplatelet therapy once anticoagulation is therapeutic 3

Statin Therapy:

• Continue atorvastatin but increase to high-intensity dose (atorvastatin 80 mg daily) regardless of baseline cholesterol 5, 4
• High-dose statins reduce recurrent stroke risk 4

Blood Pressure Management:

• After first 24 hours, restart antihypertensive therapy 3, 4
• Target BP <140/90 mmHg for secondary prevention 4
• Current regimen includes nifedipine, olmesartan, and olmesartan-HCTZ - continue these medications 3
• ACE inhibitors, calcium channel blockers, and diuretics are first-line for secondary prevention 4

Diabetes Management:

• Continue glipizide and metformin 3
• Optimize glycemic control with target HbA1c <7% 3
• Diabetes is a major risk factor for recurrent stroke 2

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Monitoring for Complications (Days 1-7)

Neurological Complications:

• Hemorrhagic transformation: Repeat CT if neurological deterioration 5
• Cerebral edema: Monitor for decreased level of consciousness, worsening neurological deficits 5
• Seizures: Treat if occur, but no prophylaxis 3

Medical Complications:

• Aspiration pneumonia: Prevented by swallowing screen and NPO status 5
• Urinary tract infection: Monitor for fever, urinalysis if suspected 3
• Deep vein thrombosis/pulmonary embolism: Prevented by pharmacologic prophylaxis, compression devices, early mobilization 3, 5
• Pressure ulcers: Frequent repositioning, early mobilization 5

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Discharge Planning (Days 5-7)

Functional Assessment:

• Comprehensive rehabilitation assessment to determine discharge disposition 5
• Options: home with outpatient therapy, home with home health services, inpatient rehabilitation facility, skilled nursing facility 5

Medication Reconciliation:

• Aspirin 81 mg + clopidogrel 75 mg daily for 21 days total (started 24 hours post-thrombolysis) 2
• Atorvastatin 80 mg nightly (increased from 10 mg) 4
• Nifedipine XL 30 mg daily 3
• Olmesartan-HCTZ 40-25 mg daily 3
• Glipizide 10 mg BID 3
• Metformin XR 1000 mg daily 3
• Famotidine 10 mg PRN 3
• Enoxaparin 40 mg subcutaneous daily (continue until fully mobile or for duration of hospitalization) 3

Patient Education:

• Stroke warning signs (FAST: Face drooping, Arm weakness, Speech difficulty, Time to call 911) 3, 7
• Importance of medication adherence 5
• Risk factor modification: blood pressure control, diabetes management, smoking cessation if applicable 2
• Call 911 immediately if any stroke symptoms recur 1

Follow-Up:

• Neurology clinic in 1-2 weeks 5
• Primary care in 1 week for medication management and blood pressure monitoring 4
• Transition from dual to single antiplatelet therapy at 21 days 2
• Repeat imaging (MRI brain) at 3-6 months if indicated 3

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Key Pitfalls to Avoid

1. Do NOT give aspirin within 24 hours of thrombolysis - increases hemorrhagic transformation risk 3, 1
2. Do NOT continue dual antiplatelet therapy beyond 21 days - increases bleeding without additional benefit 6, 4
3. Do NOT aggressively lower blood pressure in first 24 hours post-thrombolysis - may worsen ischemia 3
4. Do NOT allow oral intake before swallowing screen - risk of aspiration pneumonia 3
5. Do NOT use prophylactic anticonvulsants - may harm neurological recovery 3
6. Do NOT discharge without cardiac monitoring - may miss paroxysmal atrial fibrillation requiring anticoagulation 5
7. Do NOT forget to increase statin to high-intensity dose - critical for secondary prevention 4