What is the next step for an elderly patient with symptoms of stroke lasting 90 minutes, negative computed tomography (CT) head, and hypertension (blood pressure 165/70)?

Management of Elderly Patient with Transient Stroke Symptoms and Elevated Blood Pressure

This patient should receive intravenous alteplase (tPA) at 0.9 mg/kg (maximum 90 mg) after blood pressure is lowered to <185/110 mmHg, as symptoms lasting 90 minutes represent an acute ischemic stroke within the 3-hour treatment window, not a TIA. 1, 2

Immediate Blood Pressure Management

The patient's BP of 165/70 mmHg is below the threshold requiring treatment before tPA administration. However, you must ensure it remains <185/110 mmHg before initiating thrombolysis and maintain it <180/105 mmHg for at least 24 hours after treatment. 1, 2, 3

• If BP rises above 185/110 mmHg before tPA: Use labetalol or nicardipine to lower it below this threshold; if BP cannot be controlled, tPA is absolutely contraindicated. 2, 3
• Monitor BP every 15 minutes during infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly for 16 hours. 2, 3

Why This Patient Qualifies for Thrombolysis

Symptoms lasting 90 minutes constitute an acute ischemic stroke, not a TIA, and fall well within the 3-hour treatment window where benefit is greatest. 1, 2

• Treatment within 0-90 minutes yields the highest odds of favorable outcome (OR 2.55), and this patient at 90 minutes is at the upper end of this optimal window. 4
• The adjusted odds ratio for favorable 3-month outcome for patients treated at 91-180 minutes remains statistically significant (OR 1.64), confirming benefit even if symptoms had lasted slightly longer. 1
• Earlier treatment within 90 minutes is more likely to result in favorable outcome than treatment at 90-180 minutes. 1

Alteplase Administration Protocol

Administer 0.9 mg/kg (maximum 90 mg total) with 10% given as IV bolus over 1 minute, followed by remaining 90% infused over 60 minutes. 1, 2, 3

• Calculate total dose: patient weight in kg × 0.9 mg/kg (use maximum of 100 kg for calculation even if patient weighs more). 2
• Target door-to-needle time of <60 minutes; ideally <45 minutes. 3
• Only blood glucose assessment must precede tPA initiation; other labs should not delay treatment. 5

Critical Exclusion Criteria to Verify

Before administering tPA, confirm the patient does NOT have: 1

• Evidence of intracranial hemorrhage on CT (already confirmed negative)
• Platelet count <100,000/mm³
• INR >1.7 or PT >15 seconds (if on anticoagulants)
• Blood glucose <50 mg/dL or >400 mg/dL
• Recent stroke or head trauma within 3 months
• Recent major surgery within 14 days
• History of intracranial hemorrhage
• Seizure at stroke onset with postictal residual deficits

Post-Thrombolysis Management

Do NOT administer antiplatelet agents or anticoagulants for 24 hours after tPA. 2, 3

• Perform neurological assessment every 15 minutes during and for 2 hours after infusion, then every 30 minutes for 6 hours, then hourly for 16 hours. 3
• Monitor for symptomatic intracranial hemorrhage, which occurs in 6.4% of tPA-treated patients (vs 0.6% placebo). 1, 3
• Maintain oxygen saturation >94% with supplemental oxygen. 3
• Initiate continuous cardiac monitoring for at least 24 hours. 3

Concurrent Evaluation for Large Vessel Occlusion

Obtain CT angiography (CTA) immediately to identify large vessel occlusion, but do NOT delay tPA administration to obtain this study. 3, 5

• If large vessel occlusion is confirmed, proceed directly to mechanical thrombectomy after tPA administration (not instead of). 3, 5
• Do NOT observe after IV tPA to assess clinical response before thrombectomy, as any delay worsens outcomes. 5
• Mechanical thrombectomy should be initiated (groin puncture) within 6 hours of symptom onset if large vessel occlusion is present. 3, 5

Common Pitfalls to Avoid

Do not withhold tPA because symptoms seem "minor" or are "improving"—treatment of patients with mild ischemic stroke symptoms that are non-disabling may still be considered within 3 hours. 1, 5

• Do not delay treatment to obtain complete blood work beyond glucose; coagulation studies can be sent but should not delay tPA if no history of anticoagulant use. 1, 5
• Do not exclude elderly patients based on age alone—patients >80 years have similar symptomatic ICH rates but higher baseline mortality from comorbidities, not from tPA itself. 1
• Do not use aggressive measures to lower BP below 185/110 mmHg if it is already controlled—this patient's BP of 165/70 mmHg requires no intervention before tPA. 1, 2