What is the immediate management for a patient with an acute ischemic infarct at the posterior left temporal lobe?

Immediate Management of Acute Ischemic Infarct at the Posterior Left Temporal Lobe

All patients with acute ischemic stroke in the posterior left temporal lobe require immediate brain imaging with non-contrast CT (NCCT) to exclude hemorrhage, followed by CT angiography (CTA) from arch-to-vertex to identify large vessel occlusions, with urgent consideration for intravenous thrombolysis if presenting within 4.5 hours and endovascular thrombectomy if presenting within 6 hours. 1

Initial Assessment and Stabilization

Airway and Oxygenation

• Provide airway support and ventilatory assistance if the patient has decreased consciousness (GCS ≤10) or bulbar dysfunction to prevent aspiration. 2
• Maintain oxygen saturation ≥94% with supplemental oxygen if needed. 2, 3
• Monitor oxygen saturation continuously during the acute phase. 3

Hemodynamic Stabilization

• Assess and stabilize hemodynamic status immediately, correcting hypovolemia with normal saline. 2
• Treat cardiac arrhythmias promptly as they can compromise cerebral perfusion. 2
• Obtain an electrocardiogram immediately due to high incidence of concurrent cardiac disease. 3

Urgent Neuroimaging Protocol

Immediate Imaging Sequence

• Perform NCCT immediately without waiting for laboratory results to determine thrombolysis eligibility. 1, 3
• Complete CT angiography (CTA) from aortic arch to vertex simultaneously to identify large vessel occlusions eligible for endovascular thrombectomy. 1
• CT should be completed within 25 minutes of arrival, with interpretation within 45 minutes. 3
• Use validated triage tools such as ASPECTS to rapidly identify EVT eligibility. 1

Advanced Imaging Considerations

• CT perfusion (CTP) or multiphase CTA can be considered to assess pial collateral vessels and aid patient selection, but must not delay treatment decisions. 1
• If hemorrhage is identified on initial CT, do not proceed to CTP imaging. 1

Blood Pressure Management

For Thrombolysis Candidates

• Lower blood pressure to <185/110 mmHg before administering alteplase, then maintain <180/105 mmHg for 24 hours post-thrombolysis to reduce hemorrhagic transformation risk. 1, 2
• Use easily titratable parenteral agents such as labetalol or nicardipine. 2
• Avoid precipitous drops in blood pressure. 1

For Non-Thrombolysis Candidates

• Avoid lowering blood pressure unless systolic BP >220 mmHg or diastolic BP >120 mmHg, as aggressive reduction can worsen ischemic injury. 2
• If treatment is required, lower blood pressure cautiously by approximately 15% during the first 24 hours. 2

Laboratory Investigations

Essential Initial Tests

• Obtain electrolytes, random glucose, complete blood count, coagulation status (INR, aPTT), creatinine, and troponin immediately. 1, 3
• Do not delay imaging or treatment decisions while waiting for laboratory results, except for INR in patients on warfarin. 1, 3
• Monitor blood glucose at least four times daily for the first three days. 3

Seizure Management

Acute Seizure Treatment

• Treat new onset seizures occurring immediately before or within 24 hours of stroke onset with short-acting medications (e.g., lorazepam IV) if not self-limited. 1
• Do not initiate long-term anticonvulsant medications for a single, self-limiting immediate post-stroke seizure. 1
• Monitor for recurrent seizure activity during routine vital signs and neurological assessments. 1
• Prophylactic anticonvulsants are not recommended and may harm neural recovery. 1

Antiplatelet Therapy

Timing and Dosing

• Administer oral aspirin 160-325 mg within 24-48 hours after stroke onset for patients not receiving thrombolysis. 2, 4
• For patients receiving intravenous alteplase, delay aspirin administration until >24 hours post-thrombolysis. 2
• Stop all antiplatelet agents immediately in patients presenting on these medications if hemorrhage is present. 1

Anticoagulation Management

Acute Phase

• Do not use routine urgent anticoagulation for acute ischemic stroke, as it increases hemorrhagic risk without proven benefit for preventing early recurrent stroke. 2
• For patients on warfarin, reverse coagulopathy with prothrombin complex concentrate (PCC) and vitamin K if hemorrhage is present. 1
• For patients on DOACs, obtain urgent hematology consultation regarding reversal agents. 1

Hospital Admission and Monitoring

Admission Criteria

• Admit all patients with acute ischemic stroke to a geographically defined stroke unit with specialized interdisciplinary team care. 1, 2
• Patients presenting within 24-48 hours should be hospitalized to facilitate early deployment of therapies if symptoms recur. 1
• Monitor temperature at least four times daily for three days, treating if >37.5°C. 3

Critical Interventions to AVOID

• Do not use corticosteroids for cerebral edema management following ischemic stroke. 2
• Do not use glycoprotein IIb/IIIa inhibitors, volume expansion (hemodilution), vasodilators (pentoxifylline), or induced hypertension strategies outside clinical trials. 1, 2
• Do not use neuroprotective agents due to lack of demonstrated efficacy. 1, 2
• Do not use hyperbaric oxygen therapy except for air embolization. 2

Common Pitfalls

• Delaying imaging while waiting for laboratory results can miss the therapeutic window for thrombolysis (3-4.5 hours) and thrombectomy (6 hours). 3
• Aggressive blood pressure lowering in non-thrombolysis candidates can extend the infarct by reducing perfusion to the penumbra. 2
• Starting long-term anticonvulsants after a single seizure may impair neural recovery without proven benefit. 1
• Premature decisions about DNR status or palliative care should be deferred for 24-48 hours to allow time for response to medical therapy. 1