What is the initial management for a patient with acute ischemic stroke presenting with severe right-sided deficits, punctated acute infarcts of the left basal ganglia, and white matter infarct, along with mild chronic microangiopathy, and does this patient require a beta blocker, such as metoprolol (metoprolol tartrate), and aspirin (acetylsalicylic acid)?

Acute Ischemic Stroke Management with Severe Right-Sided Deficits

Immediate Antiplatelet Therapy

Administer oral aspirin 325 mg within 24-48 hours after stroke onset, but only after ruling out hemorrhagic stroke with CT imaging and confirming the patient is not receiving or eligible for thrombolytic therapy. 1, 2

• Aspirin reduces early recurrent stroke by approximately 7 per 1000 patients and overall death or further stroke by 9 per 1000 patients when started within 48 hours of acute ischemic stroke 3, 4
• Do not give aspirin within 24 hours if the patient received IV alteplase (rtPA), as this significantly increases hemorrhagic risk 3
• The benefit of aspirin is primarily through prevention of early recurrent stroke rather than limiting the neurological consequences of the acute stroke itself 3

Beta Blocker Use: Exercise Extreme Caution

Beta blockers like metoprolol should generally be avoided or used with extreme caution in acute ischemic stroke, as aggressive blood pressure lowering can worsen cerebral perfusion and expand infarct size. 3, 2

Blood Pressure Management Guidelines:

• For patients NOT receiving thrombolysis: Withhold antihypertensive medications unless systolic BP >220 mmHg or diastolic BP >120 mmHg 3, 2
• Blood pressure often declines spontaneously when the patient rests in a quiet room, the bladder is emptied, and pain is controlled 3
• Aggressive BP lowering can reduce perfusion to ischemic penumbra and potentially expand infarct size 3

When Beta Blockers May Be Considered:

• If BP remains >220/120 mmHg despite conservative measures, use easily titratable IV agents like labetalol (10-20 mg IV over 1-2 minutes) rather than oral metoprolol 3
• For concurrent acute myocardial infarction or acute pulmonary edema, beta blockers may be necessary despite stroke, but use with careful BP monitoring 3
• Target a cautious 10-15% reduction in BP, not normalization 3, 2

Anticoagulation: Not Recommended Acutely

Urgent anticoagulation is not recommended for acute ischemic stroke management, even with basal ganglia infarcts, as it does not reduce early recurrent stroke or improve outcomes but increases hemorrhagic complications. 3

• Multiple trials demonstrate that early anticoagulation (UFH or LMWH) does not lessen early neurological worsening or reduce early recurrent stroke risk 3
• Anticoagulation significantly increases risk of symptomatic intracranial hemorrhage, particularly in moderate-to-severe strokes 3
• The usefulness of urgent anticoagulation even for high-risk scenarios (severe carotid stenosis, vertebrobasilar disease) is not well established 3

Critical Management Priorities for This Patient

Immediate Assessment (Within Minutes):

• Non-contrast CT to confirm ischemic stroke and rule out hemorrhage 1, 2
• Assess eligibility for IV thrombolysis if within 3-4.5 hours of symptom onset 1, 2
• CT angiography if within 6 hours to identify large vessel occlusion for potential thrombectomy 1, 2
• 12-lead ECG to identify atrial fibrillation (but don't delay thrombolysis assessment) 1, 2

Supportive Care:

• Maintain oxygen saturation >94% with supplemental oxygen 1, 2
• Correct hypoglycemia (<60 mg/dL); treat hyperglycemia to achieve glucose 140-180 mg/dL 2
• Correct hypovolemia with IV normal saline 2
• Admit to specialized stroke unit within 24 hours 1, 2

Avoid Common Pitfalls:

• Do not routinely lower blood pressure - this is the most critical error in acute stroke management 3, 2
• Do not substitute aspirin for acute interventions like thrombolysis or thrombectomy 3
• Do not use corticosteroids for cerebral edema management 1, 2
• Do not start anticoagulation urgently, even with chronic microangiopathy 3

Clinical Algorithm Summary

1. Hour 0-3: Assess for IV thrombolysis eligibility; if eligible, strict BP control <185/110 before and <180/105 after rtPA 1, 2
2. Hour 0-6: Assess for endovascular thrombectomy if large vessel occlusion 1, 2
3. Hour 24-48: Start aspirin 325 mg if NOT given thrombolysis (or after 24 hours if thrombolysis given) 3, 1, 2
4. Ongoing: Permissive hypertension unless BP >220/120 mmHg; avoid beta blockers unless specific cardiac indication 3, 2
5. Secondary prevention: Evaluate stroke etiology to guide long-term anticoagulation decisions (not acute management) 2