What is the emergency therapy for a patient with an acute non-hemorrhagic infarct in the right frontal, parietal, and posterior occipital lobe?

Emergency Therapy for Acute Non-Hemorrhagic Infarct in Right Frontal, Parietal, and Posterior Occipital Lobes

This patient requires immediate ABC stabilization, urgent non-contrast CT to confirm non-hemorrhagic stroke, and intravenous alteplase (rtPA) 0.9 mg/kg (maximum 90 mg) if presenting within 4.5 hours of symptom onset and meeting eligibility criteria, followed by consideration for mechanical thrombectomy if large vessel occlusion is identified. 1, 2

Immediate Stabilization (First 15 Minutes)

• Assess and stabilize airway, breathing, and circulation with the same priority as acute myocardial infarction or serious trauma 1, 2
• Patients with posterior circulation involvement (occipital lobe) may require aggressive airway management if altered consciousness is present 1
• Establish cardiac monitoring immediately to identify atrial fibrillation, acute myocardial infarction, or other arrhythmias 1, 2
• Obtain intravenous access and draw blood for: complete blood count (platelet count), PT/INR, aPTT, glucose, and basic metabolic panel 1
• Determine exact time of symptom onset (witnessed or last known normal) as this is critical for treatment eligibility 1, 2
• Perform rapid neurological examination using the National Institutes of Health Stroke Scale (NIHSS) to quantify deficit severity 1, 2, 3

Urgent Neuroimaging (Within 25 Minutes of Arrival)

• Obtain non-contrast CT brain immediately to exclude intracranial hemorrhage and confirm ischemic stroke 1, 2, 3
• The CT scan should be completed within 25 minutes of arrival and interpreted within 45 minutes by a physician with expertise in reading brain imaging 1
• Obtain CT angiography (CTA) of head and neck simultaneously with non-contrast CT to identify large vessel occlusions, but do not delay rtPA administration 1, 3
• Frank hypodensity involving more than one-third of the MCA territory is a contraindication to intravenous rtPA 1

Blood Pressure Management

If Patient is rtPA Eligible (Within 4.5 Hours):

Pretreatment blood pressure must be reduced to <185/110 mmHg:

• Labetalol 10-20 mg IV over 1-2 minutes; may repeat once, OR 1
• Nicardipine 5 mg/h IV infusion, titrate up by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h), OR 1
• Nitropaste 1-2 inches 1
• If blood pressure cannot be reduced and maintained below 185/110 mmHg, do not administer rtPA 1

During and after rtPA infusion (for 24 hours):

• Monitor blood pressure every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then every hour for 16 hours 1
• Maintain blood pressure <180/105 mmHg 2
• If systolic BP 180-230 mmHg or diastolic BP 105-120 mmHg: Labetalol 10 mg IV over 1-2 minutes, may repeat every 10-20 minutes (maximum 300 mg) OR Nicardipine 5 mg/h IV, titrate by 2.5 mg/h every 5 minutes to maximum 15 mg/h 1
• If diastolic BP >140 mmHg: Sodium nitroprusside 0.5 μg/kg/min IV infusion with continuous blood pressure monitoring 1

If Patient is NOT rtPA Eligible:

• Consider lowering blood pressure only if systolic BP >220 mmHg or diastolic BP >120 mmHg 1
• Target: reduce blood pressure by 15-25% within the first day 1

Intravenous Thrombolysis Protocol

Inclusion Criteria for rtPA (0-3 Hours):

• Diagnosis of ischemic stroke causing measurable neurologic deficit 1
• Onset of symptoms <3 hours before beginning treatment 1
• Age ≥18 years 1

Additional Inclusion Criteria for rtPA (3-4.5 Hours):

• Same as above, but onset 3-4.5 hours before treatment 1
• Exclude if: Age >80 years, NIHSS >25, taking oral anticoagulant regardless of INR, or history of both diabetes and prior ischemic stroke 1

Key Exclusion Criteria:

• Head trauma or prior stroke in previous 3 months 1
• History of intracranial hemorrhage 1
• Elevated blood pressure (systolic >185 mmHg or diastolic >110 mmHg) that cannot be controlled 1
• Platelet count <100,000/mm³ 1
• INR >1.7 or PT >15 seconds 1
• Heparin within 48 hours with elevated aPTT 1
• Blood glucose <50 mg/dL 1
• CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere) 1

rtPA Dosing and Administration:

• Alteplase 0.9 mg/kg (maximum 90 mg) administered as 10% bolus over 1 minute, followed by 90% infusion over 60 minutes 1, 4, 5, 6
• Treatment can be initiated before coagulation results are available if no recent anticoagulant use, but discontinue if INR >1.7 or platelets <100,000/mm³ 1

Mechanical Thrombectomy Consideration

• If CTA reveals large vessel occlusion (internal carotid artery, M1 or M2 segment of middle cerebral artery), contact interventional neuroradiology immediately for mechanical thrombectomy 1, 2, 3
• Mechanical thrombectomy improves functional independence when performed within 6 hours (46.0% vs 26.5% with medical therapy alone) 1, 5
• Can be performed up to 24 hours after symptom onset if perfusion imaging shows large ratio of ischemic to infarcted tissue 1, 5
• Do not delay rtPA administration while arranging mechanical thrombectomy 1

Supportive Care and Monitoring

Oxygenation and Positioning:

• Administer supplemental oxygen only if patient is hypoxic (oxygen saturation <94%) 1
• Position head of bed at 25-30° if increased intracranial pressure is suspected until imaging rules out space-occupying lesions 1

Temperature Management:

• Measure temperature frequently (at least every 30 minutes in ED) 1
• Treat fever >99.6°F (37.6°C) as hyperthermia is associated with poor outcomes 1

Neurological Monitoring:

• For patients receiving rtPA: Neurological assessment and vital signs every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then every 60 minutes for 16 hours (total 24 hours) 1
• For patients not receiving rtPA: Follow institutional protocol for neurological checks 1

NPO Status and Swallowing:

• Keep patient NPO until swallowing screening is performed within 24 hours using a validated tool 2
• Do not allow any oral intake before swallowing safety is confirmed 2

Acute Stroke Unit Admission

• Admit all stroke patients to a specialized stroke unit with dedicated, trained interdisciplinary staff 2
• Continue cardiac monitoring for at least 24 hours to screen for atrial fibrillation 2
• Apply intermittent pneumatic compression devices immediately for immobilized patients to prevent deep vein thrombosis 2, 7

Critical Pitfalls to Avoid

• Do not delay rtPA for advanced imaging (perfusion CT, MRI) if patient is within treatment window and meets basic eligibility criteria 1, 3
• Do not administer rtPA if blood pressure cannot be controlled below 185/110 mmHg despite aggressive management 1
• Do not assume early CT changes mean "too late" - early ischemic changes (other than frank hypodensity) are not contraindications to rtPA 1
• Do not give aspirin or other antiplatelet agents for 24 hours after rtPA to minimize bleeding risk 5
• Circulatory collapse or cardiac arrest is uncommon in isolated ischemic stroke and suggests other conditions like acute myocardial infarction requiring simultaneous management 1