What is the appropriate management for an elderly patient with a history of spontaneous intracranial hemorrhage (ICH) presenting with acute onset of slurred speech and left-sided weakness?

Management of Acute Ischemic Stroke in a Patient with Prior Spontaneous ICH

Hold thrombolytics and admit to a stroke unit. This patient presents with acute ischemic stroke symptoms (slurred speech, left-sided weakness within 45 minutes) but has a critical contraindication to thrombolytic therapy: a history of spontaneous intracranial hemorrhage.

Rationale for Withholding Thrombolytics

Prior spontaneous ICH is an absolute contraindication to IV thrombolysis. While the 2023 World Stroke Organization guidelines strongly recommend IV thrombolysis for eligible acute ischemic stroke patients 1, this recommendation explicitly applies only to patients without contraindications. A history of spontaneous intracranial hemorrhage represents one of the most significant risk factors for hemorrhagic transformation with thrombolytic therapy 2.

Key Risk Considerations:

• Recurrence risk: Patients with prior ICH have a 6-fold higher risk of recurrent ICH compared to those with prior ischemic stroke (HR 6.60,95% CI 4.50-9.68) 1
• Hemorrhagic complications: Thrombolytic therapy carries a 3-9% risk of symptomatic ICH in general stroke populations, with 60% mortality when it occurs 1
• Elderly patients with prior ICH: This population has particularly elevated risk due to potential underlying cerebral amyloid angiopathy 1

Blood Pressure Management

The patient's BP of 173/97 mmHg does not require immediate aggressive parenteral treatment in the acute ischemic stroke setting without thrombolysis 1. The 2023 guidelines recommend permissive hypertension in acute ischemic stroke patients who are not receiving thrombolysis, as cerebral perfusion may be pressure-dependent 1.

Avoid aggressive BP lowering in acute ischemic stroke without thrombolysis, as this differs fundamentally from acute ICH management where intensive BP reduction to <140 mmHg is recommended 1.

Appropriate Care Setting

Admission to a stroke unit is strongly recommended rather than a regular inpatient bed 1. The 2014 ESO guidelines provide high-quality evidence that acute stroke unit care reduces both death and dependency for all stroke patients, including those with contraindications to thrombolysis 1.

Stroke Unit Benefits:

• Specialized multidisciplinary care with vascular neurology expertise 1
• Protocols for monitoring neurological deterioration 1
• Early mobilization and rehabilitation services 1
• Reduced mortality and improved functional outcomes compared to general wards 1

Alternative Acute Interventions to Consider

While thrombolysis is contraindicated, the stroke unit team should evaluate:

• Mechanical thrombectomy eligibility: If large vessel occlusion is suspected, non-invasive angiography (CTA) should be performed 1. Mechanical thrombectomy may be considered in select patients even without thrombolysis, though prior ICH increases procedural risk
• Antiplatelet therapy: Aspirin within 48 hours of ischemic stroke onset (after excluding hemorrhage on CT) remains appropriate 1
• Secondary prevention planning: Given dual stroke pathology risk (both ischemic and hemorrhagic), careful long-term management is essential 1

Common Pitfall to Avoid

Do not delay stroke unit admission while debating thrombolysis eligibility. The history of spontaneous ICH makes this decision straightforward—thrombolysis is contraindicated. Time should instead focus on rapid stroke unit transfer, supportive care, and evaluation for mechanical thrombectomy if appropriate 1.