What is the management and blood pressure target for a patient with a right hemispheric stroke (Right TACI) and post-stroke seizure, with a National Institutes of Health Stroke Scale (NIHSS) score of severe impairment?

Management of Right TACI with Post-Stroke Seizure (NIHSS 26)

Blood Pressure Management

For this severe stroke patient (NIHSS 26) who is not a thrombolysis candidate, blood pressure should only be lowered if systolic BP exceeds 220 mmHg or diastolic BP exceeds 120 mmHg. 1

• The Canadian Stroke Best Practice guidelines explicitly state that for patients not receiving thrombolytic therapy, aggressive blood pressure lowering is contraindicated below these thresholds because it may decrease perfusion pressure and worsen ischemia in the penumbral zone where autoregulation is lost 1

• If the patient had received thrombolytic therapy, the target would be more stringent: maintain BP <180/105 mmHg for 24 hours post-thrombolysis 1

• Avoid rapid BP reduction regardless of the degree of hypertension, as this can worsen ischemic injury by reducing cerebral perfusion pressure in areas where autoregulation has failed 1

Approach to Elevated Blood Pressure:

• First assess and treat reversible causes: hypoxia, increased intracranial pressure, hemorrhagic transformation, full bladder, pain, nausea, or environmental factors 1
• Monitor BP continuously during the acute phase 1
• Only initiate antihypertensive treatment when SBP >220 mmHg or DBP >120 mmHg 1

Seizure Management

A single self-limited seizure occurring at stroke onset or within 24 hours should be treated acutely with short-acting medications (e.g., lorazepam IV) if not self-limited, but should NOT be followed by long-term anticonvulsant therapy. 1

Acute Seizure Treatment Protocol:

• Administer lorazepam IV for active seizures that are not self-limited 1
• Monitor closely for recurrent seizure activity during routine vital sign checks and neurological assessments 1

Long-term Anticonvulsant Decisions:

• Do NOT start prophylactic anticonvulsants - there is no evidence supporting this practice and it is explicitly not recommended 1
• Only initiate long-term anticonvulsant therapy if the patient experiences recurrent seizures (more than one seizure episode) 1
• If recurrent seizures occur, treat according to standard seizure management protocols used for other neurological conditions 1

Monitoring Strategy:

• Assess for seizure activity during each vital sign check and neurological examination 1
• Consider EEG monitoring if there is unexplained reduced level of consciousness 1

Additional Critical Management Considerations

Prognostic Context:

• An NIHSS score of 26 forecasts a high probability of death or severe disability, as scores >16 are associated with poor outcomes 1, 2
• This severe deficit indicates the patient will likely require intensive rehabilitation if they survive the acute phase 1

Early Stabilization Priorities:

• Assess and secure airway, breathing, and circulation immediately 1
• Monitor oxygen saturation and maintain PO₂ >90 mmHg 1
• Check temperature regularly - even 1°F elevation worsens outcomes and increases mortality 1
• Assess hydration status and correct volume depletion with normal saline if hypotensive 1
• Monitor cardiac rhythm continuously for arrhythmias 1

Laboratory Monitoring:

• Obtain acute blood work: electrolytes, glucose, CBC with platelets, coagulation studies (INR, aPTT), and creatinine 1
• Monitor glucose every 6 hours if diabetic 1
• These tests should not delay imaging or treatment decisions 1

Early Mobilization:

• Begin rehabilitation therapy as soon as medical stability is reached 1
• Start range-of-motion exercises and position changes on day of admission to prevent DVT, skin breakdown, contractures, constipation, and pneumonia 1
• Despite the severe NIHSS score, early mobilization improves functional outcomes 1