What is the best management approach for a 60-year-old woman with a stroke, presenting with right-sided facial droop and paresthesia in the right upper extremity, who is taking Abilify (aripiprazole), aspirin, atorvastatin, losartan, and omeprazole, and has a history of old bilateral cerebral hemispheric infarcts with superficial siderosis and a probable 14 mm left frontal convexity meningioma, and is requesting Benadryl (diphenhydramine) for itchy hands?

Management of Acute Stroke with Superficial Siderosis: Critical Medication Decisions

This patient should NOT receive Benadryl (diphenhydramine) due to the high risk of cognitive impairment and potential worsening of stroke recovery, and her current aspirin therapy should be continued while avoiding dual antiplatelet therapy given her superficial siderosis and hemorrhage risk.

Immediate Stroke Management (18 Hours Post-Onset)

Antiplatelet Therapy Decision

• Continue aspirin monotherapy as the patient is already on aspirin and is outside the thrombolysis window (>4.5 hours) 1
• The patient's aspirin should be maintained at 81-325 mg daily for secondary stroke prevention in this non-cardioembolic stroke 1
• Do NOT add clopidogrel to create dual antiplatelet therapy beyond 21 days, as this increases bleeding risk without additional benefit, particularly concerning given her superficial siderosis 1, 2

Critical Contraindication: Superficial Siderosis

• Superficial siderosis represents hemosiderin deposition from prior microhemorrhages, creating a significantly elevated risk for future intracranial hemorrhage 3
• This finding makes aggressive antiplatelet or anticoagulation strategies particularly dangerous 3
• The presence of bilateral old infarcts with superficial siderosis suggests cerebral amyloid angiopathy or chronic small vessel disease with hemorrhagic tendency 3

The Benadryl Request: A Critical Safety Issue

Why Diphenhydramine Must Be Avoided

• Neuroleptics, benzodiazepines, and centrally-acting anticholinergic agents (including diphenhydramine) are explicitly recommended AGAINST during stroke recovery due to impaired neurological recovery 1
• Diphenhydramine causes significant CNS sedation even in "non-sedating" formulations, with variable penetration that can cause drowsiness, cognitive impairment, and antimuscarinic effects 4
• In a 60-year-old stroke patient with existing neurological deficits, anticholinergic medications can worsen confusion, impair rehabilitation participation, and increase fall risk 1

Safe Alternatives for Pruritus

• Non-sedating antihistamines (cetirizine 10 mg daily, loratadine 10 mg daily, or fexofenadine 180 mg daily) are safer alternatives with minimal CNS penetration 4
• Topical treatments (moisturizers, topical corticosteroids for localized areas) should be first-line for hand pruritus
• Investigate underlying causes: dry skin, medication side effects (atorvastatin rarely causes pruritus), or unrelated dermatological conditions

Abilify (Aripiprazole) Consideration

Potential Concern

• Centrally-acting medications should be used cautiously during stroke recovery, weighing benefits against potential adverse effects on outcome 1
• If aripiprazole is being used for psychiatric indications (depression, psychosis), the benefit may outweigh risks, but this should be reassessed
• If prescribed for non-essential indications, consider tapering or discontinuation during acute recovery phase

Secondary Prevention Optimization

Lipid Management

• Continue atorvastatin with target LDL <70 mg/dL (1.8 mmol/L) for secondary stroke prevention 1, 2
• High-dose statin therapy (atorvastatin 80 mg daily) is recommended for all patients with ischemic stroke 1, 2, 5

Blood Pressure Management

• Continue losartan with target systolic BP <140 mmHg for patients with intracranial atherosclerotic disease 1, 2
• Avoid centrally-acting alpha-2 agonists (clonidine) and alpha-1 antagonists (prazosin) as they may impair stroke recovery 1

Proton Pump Inhibitor

• Omeprazole continuation is reasonable given chronic aspirin use to reduce GI bleeding risk, though not specifically mandated by stroke guidelines 1

Meningioma Management

Thrombolysis Considerations (Retrospective)

• While this patient is beyond the thrombolysis window, extra-axial benign tumors like meningiomas are not absolute contraindications to thrombolysis if otherwise indicated 6
• The 14 mm left frontal convexity meningioma likely did not contribute to the right-sided symptoms (wrong hemisphere for facial droop/right arm symptoms) 6

Ongoing Monitoring

• The meningioma requires neurosurgical follow-up but does not alter acute stroke management
• Antiplatelet therapy is not contraindicated by the presence of meningioma 6

Summary Algorithm

1. Continue aspirin monotherapy (81-325 mg daily) - do not add clopidogrel given superficial siderosis 1, 2
2. Refuse diphenhydramine - offer non-sedating antihistamine (cetirizine 10 mg daily) or topical therapy instead 1, 4
3. Continue atorvastatin targeting LDL <70 mg/dL 1, 2
4. Continue losartan targeting BP <140/90 mmHg 1, 2
5. Reassess aripiprazole necessity during recovery period 1
6. Arrange neurosurgical consultation for meningioma surveillance (non-urgent) 6
7. Monitor for post-stroke epilepsy given superficial siderosis (48.9% association with seizures) 3