What is the appropriate management for a patient presenting with unilateral weakness, slurred speech, and hypertension, suggestive of a stroke?

Acute Stroke Management

This patient requires immediate activation of stroke protocols with urgent brain imaging (CT or MRI) to differentiate ischemic from hemorrhagic stroke, followed by consideration for thrombolytic therapy if presenting within 4.5 hours of symptom onset and imaging confirms ischemic stroke without contraindications. 1

Immediate Assessment and Stabilization

Airway, Breathing, and Circulation

• Rapidly assess airway patency, breathing adequacy, and circulatory status as the first priority 1
• Administer supplementary oxygen only if oxygen saturation is <94% or unknown; routine oxygen is not indicated for normoxic patients 1
• Monitor for respiratory compromise as hypoxemia combined with poor perfusion will extend ischemic brain injury 1

Neurological Assessment

• Perform immediate neurological examination using a standardized stroke scale (NIHSS preferred) to quantify stroke severity and monitor for evolving changes 1, 2
• Document the exact time of symptom onset or last known well time, as this determines eligibility for acute interventions 1, 2
• The clinical presentation (left-sided hemiparesis, dysarthria, sensory deficits) indicates a right hemispheric stroke 3

Vital Signs Monitoring

• Assess heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and seizure activity 1
• The patient's heart rate of 56 bpm warrants cardiac rhythm monitoring to exclude bradyarrhythmias or heart block 1

Blood Pressure Management

For Non-Thrombolysis Candidates

Do not aggressively lower blood pressure unless systolic BP exceeds 220 mmHg or diastolic BP exceeds 120 mmHg. 1, 4

• This patient's BP of 150-160/80-90 mmHg should be monitored but NOT actively treated in the acute phase 1, 4
• Permissive hypertension is recommended because aggressive BP reduction may decrease cerebral perfusion pressure and worsen ischemia 1, 4
• If treatment is required for extreme hypertension, lower BP by only 15% during the first 24 hours using labetalol, nicardipine, or sodium nitroprusside 4

For Thrombolysis Candidates

• If the patient is eligible for IV thrombolysis, BP must be reduced to and maintained below 185/110 mmHg before and during the first 24 hours of treatment 1, 4

Avoid Hypotension

• Do not initiate antihypertensive intervention if systolic BP is <90 mmHg, as hypotension worsens cerebral ischemia 1
• The brain is especially vulnerable to hypotension during acute stroke due to impaired cerebral autoregulation 1

Urgent Diagnostic Workup

Imaging (Priority #1 - Do Not Delay)

• Obtain immediate non-contrast CT brain or MRI to differentiate ischemic from hemorrhagic stroke 1, 3, 2
• Perform non-invasive vascular imaging (CTA or MRA from aortic arch to vertex) to identify large vessel occlusion for potential endovascular therapy 3, 2
• Do not delay imaging to obtain ECG or chest X-ray unless the patient is hemodynamically unstable 1

Laboratory Tests

• Draw blood immediately for: glucose, electrolytes, CBC, coagulation studies (INR, aPTT), creatinine, eGFR, and troponin 1, 3
• Critical: Do not wait for laboratory results before proceeding with imaging or thrombolysis decisions unless the patient is on warfarin (requiring INR) or has suspected coagulopathy 1
• For patients with known renal impairment, weigh the benefit of immediate CTA against waiting for creatinine results, favoring "neurons over nephrons" in disabling strokes 1

Cardiac Evaluation

• Obtain ECG but defer until after thrombolysis decision if patient is hemodynamically stable 1
• The bradycardia (HR 56) necessitates ECG to exclude heart block or other arrhythmias 1
• Defer chest X-ray unless acute cardiac or pulmonary disease is suspected 1

Acute Treatment Considerations

Thrombolytic Therapy

• If ischemic stroke is confirmed on imaging and the patient presents within 4.5 hours of symptom onset (or last known well), assess eligibility for IV alteplase (0.9 mg/kg) 1, 2
• Extended time windows up to 9 hours may be possible with specialized MRI studies, and up to 24 hours for endovascular therapy in selected patients with large vessel occlusion 1, 2

Fluid Management

• Initiate isotonic intravenous fluids (0.9% normal saline) to maintain euvolemia 1
• Avoid hypotonic solutions (5% dextrose, 0.45% saline) as they distribute into intracellular spaces and may exacerbate cerebral edema 1
• Estimate maintenance fluid requirements at 30 mL/kg body weight per day 1

Critical Pitfalls to Avoid

• Do not aggressively lower this patient's BP of 150-160/80-90 mmHg unless thrombolysis is planned; permissive hypertension protects the ischemic penumbra 1, 4
• Do not delay imaging or treatment to obtain ECG, chest X-ray, or await laboratory results unless clinically indicated 1
• Do not discharge from ED without completing diagnostic evaluation, initiating secondary prevention, and establishing follow-up plan 1
• Do not administer hypotonic IV fluids as they worsen cerebral edema 1

Post-Acute Management (After 24 Hours)

• Initiate long-term antihypertensive therapy after the first 24 hours, individualizing based on comorbidities and ability to swallow 1
• Address secondary stroke prevention including antiplatelet therapy, statin therapy, and risk factor modification 3
• Target long-term BP <130/80 mmHg for secondary prevention, though this should be individualized based on stroke subtype and vascular disease burden 5