What is the treatment for a patient with a history of alcohol use disorder, presenting with hypertension and left-sided weakness, and an MRI showing an acute infarct in the right cerebellum?

Treatment of Acute Cerebellar Infarct with Hypertension

This patient requires urgent blood pressure control to <185/110 mmHg if thrombolysis is being considered, or cautious reduction only if BP >220/120 mmHg if thrombolysis is contraindicated, along with aspirin 150-300 mg within 48 hours, stroke unit admission, and careful monitoring for cerebellar edema requiring neurosurgical evaluation.

Immediate Assessment and Thrombolysis Eligibility

Blood Pressure Management Strategy

The approach to blood pressure control depends entirely on whether the patient is a candidate for thrombolytic therapy:

For patients eligible for IV tPA:

• Blood pressure must be reduced to <185 mmHg systolic and <110 mmHg diastolic before initiating thrombolysis to limit bleeding risk 1
• If BP is 180-230 mmHg systolic or 105-120 mmHg diastolic, use:
  • Labetalol 10 mg IV followed by continuous infusion 2-8 mg/min, OR
  • Nicardipine IV 5 mg/hr, titrated by 2.5 mg/hr every 5-15 minutes to maximum 15 mg/hr 1
• After thrombolysis initiation, maintain BP <180/105 mmHg for at least 24 hours with monitoring every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1, 2

For patients NOT eligible for thrombolysis:

• Only treat BP if systolic >220 mmHg or diastolic >120 mmHg 1
• Target a cautious 10-15% reduction in BP within the first 24 hours 1
• Avoid aggressive BP lowering, as elevated BP may represent compensatory cerebral perfusion to ischemic tissue 1

Thrombolysis Considerations

Inclusion criteria for IV tPA (within 3-4.5 hours):

• Measurable neurologic deficit from ischemic stroke 1
• Symptom onset <4.5 hours (stronger evidence within 3 hours) 1, 3
• MRI confirms acute infarct without hemorrhage 1

Critical exclusion criteria relevant to this patient:

• History of alcohol use is NOT an absolute contraindication 4
• Elevated BP >185/110 mmHg (must be controlled first) 1
• Platelet count <100,000/mm³, INR >1.7, or glucose <50 mg/dL 1
• Recent alcohol intoxication within 24 hours may increase embolic stroke risk but is not listed as formal exclusion 5

Important caveat: While alcohol use disorder itself is not a contraindication, active alcohol withdrawal increases complications and mortality after stroke 6. Assess for withdrawal symptoms and treat prophylactically if indicated.

Acute Stroke Management

Antithrombotic Therapy

• Aspirin 150-300 mg should be given within 48 hours after CT/MRI excludes hemorrhage 1
• If thrombolysis is administered, delay aspirin for 24 hours post-tPA 1
• Routine anticoagulation with heparin is NOT recommended for unselected acute ischemic stroke patients 1

Cerebellar Stroke-Specific Concerns

Urgent neurosurgical consultation is critical for cerebellar infarcts:

• Cerebellar infarcts carry high risk of life-threatening edema and brainstem compression 1
• Monitor closely for signs of deterioration: decreased consciousness, new cranial nerve deficits, respiratory compromise 1
• Surgical decompression may be lifesaving if significant edema develops (analogous to hemicraniectomy for malignant MCA infarction) 1

Stroke Unit Care

• All acute stroke patients should be admitted to a dedicated stroke unit, which reduces mortality and improves functional outcomes 2
• Maintain NPO status until formal swallowing screen completed to prevent aspiration pneumonia 2
• Monitor for complications: hemorrhagic transformation, cerebral edema, seizures, aspiration pneumonia, DVT, pressure ulcers 2

Alcohol-Related Considerations

Alcohol Withdrawal Prevention

Given the history of alcohol use:

• Assess for alcohol withdrawal using CIWA-Ar protocol 6
• Alcohol withdrawal is associated with 32% increased mortality and >50% increased odds of medical complications (pneumonia, sepsis, UTI) after stroke 6
• Consider prophylactic benzodiazepines if heavy recent use or prior withdrawal history 6

Impact on Stroke Risk and Outcomes

• Recent heavy drinking (>40g within 24 hours) increases risk of embolic stroke, particularly cardioembolic and cryptogenic subtypes 5
• However, history of alcohol use does NOT increase symptomatic intracranial hemorrhage risk with tPA (8.3% vs 4.3% in non-alcohol patients, though this difference was significant) 4
• Patients with alcohol history who receive tPA have similar 90-day functional outcomes and mortality compared to those without alcohol history 4

Secondary Prevention Initiation

After the acute phase (>24 hours post-thrombolysis or immediately if no thrombolysis):

• High-intensity statin therapy (atorvastatin 80 mg daily) regardless of baseline cholesterol 2
• Antihypertensive therapy targeting <140/90 mmHg after acute period 2
• Dual antiplatelet therapy (aspirin + clopidogrel) for 21 days for minor-to-moderate stroke, then single agent 2
• Address modifiable risk factors: smoking cessation, alcohol reduction, diabetes control 1

Critical Pitfalls to Avoid

• Do not aggressively lower BP in non-thrombolysis candidates unless >220/120 mmHg, as this may worsen cerebral perfusion 1
• Do not delay thrombolysis for advanced imaging (CTA, perfusion studies) if patient is within time window and meets clinical criteria 1
• Do not dismiss alcohol history as contraindication to tPA if patient otherwise qualifies 4
• Do not overlook alcohol withdrawal risk, which dramatically worsens stroke outcomes 6
• Do not underestimate cerebellar stroke severity—these require close monitoring and low threshold for neurosurgical consultation due to edema risk 1