What is the next step in management for a 74-year-old female patient with left-sided weakness, atrial fibrillation (Afib), diabetes, and hypertension, presenting 3 hours after symptom onset with elevated blood pressure (hypertension), and no hemorrhage or large vessel occlusion on stat noncontrast head computed tomography (CT) and computed tomography angiography (CTA)?

Administer Tissue Plasminogen Activator (tPA)

The AGACNP should order tissue plasminogen activator (tPA) immediately (Option C), as this patient presents within the 3-hour window for acute ischemic stroke with no hemorrhage on CT and no absolute contraindications to thrombolytic therapy.

Rationale for tPA Administration

This patient meets the criteria for IV tPA based on the following:

• Time window: Symptom onset 3 hours prior to arrival falls within the Class I, Level A recommendation for tPA administration within 3 hours of symptom onset 1
• Imaging complete: Noncontrast head CT and CTA have already excluded intracranial hemorrhage (absolute contraindication) and large vessel occlusion 1
• No documented contraindications: The patient has atrial fibrillation, but there is no mention of current anticoagulation therapy that would preclude tPA use 2

Blood Pressure Management Timing

The elevated blood pressure (198/99 mmHg) should NOT delay tPA administration. Blood pressure management occurs as part of the tPA protocol, not before it:

• Blood pressure control is integrated into acute stroke management but should not delay thrombolytic therapy when the patient is within the treatment window 1
• Labetalol administration (Option B) would be appropriate during or after tPA initiation, not as a prerequisite that delays treatment 1
• The priority is "door-to-tPA time" with a goal of <60 minutes, and any delays reduce the likelihood of favorable outcomes 3, 4, 5

Why Other Options Are Incorrect

Option A (MRI of the brain): While MRI with diffusion-weighted imaging is more sensitive than CT for detecting acute ischemia, it is only recommended "if this does not unduly delay the administration of intravenous tPA" 1. Since this patient is already within 3 hours and has adequate CT imaging excluding hemorrhage, obtaining an MRI would cause unacceptable delay 1, 4

Option D (Repeat head CT): A stat head CT was already obtained and showed no hemorrhage. Repeating imaging would only delay treatment without clinical benefit 1

Critical Time-Dependent Considerations

• Every minute counts: The benefit of tPA decreases significantly with time, with the greatest benefit occurring when treatment is initiated as early as possible within the 3-hour window 4, 5
• Number needed to treat: Within the 3-hour window, the NNT is 8 for improved functional outcomes 2
• Door-to-needle goal: The Emergency Department standard is door-to-tPA administration within 60 minutes 5

Common Pitfalls to Avoid

• Do not delay for "perfect" blood pressure control: While severe hypertension can be a relative contraindication, blood pressure management should occur concurrently with tPA preparation, not sequentially 1
• Do not pursue additional imaging within the treatment window: The patient already has adequate imaging to exclude hemorrhage and proceed with treatment 1
• Do not assume atrial fibrillation equals anticoagulation: The question does not state the patient is currently on anticoagulation; atrial fibrillation alone is not a contraindication to tPA 2