What is the primary impression and next step in management for a female patient with a history of hypertension, presenting with sudden onset of headache, dizziness, left-sided numbness, elevated blood pressure, and weakness in the left upper and lower extremities?

Primary Impression: Acute Ischemic Stroke (Left MCA Territory) - Hypertensive Emergency

This patient requires immediate ICU admission and urgent neuroimaging (CT/CTA or MRI) to confirm acute stroke and determine eligibility for reperfusion therapy. 1

Clinical Reasoning

This presentation strongly suggests acute ischemic stroke based on:

• Sudden onset left-sided hemiparesis (LUE/LLE 2/5) with facial involvement
• Left hemisensory loss
• Dysarthria (lower volume speech)
• Acute headache with vomiting
• Severely elevated BP (200/120 mmHg) with acute neurologic deficits constituting target organ damage 1

The blood pressure of 200/120 mmHg WITH acute neurologic dysfunction defines a hypertensive emergency, not urgency, requiring immediate ICU-level care with continuous arterial monitoring and parenteral therapy. 1

Differential Diagnoses (in order of likelihood)

1. Acute ischemic stroke (left MCA territory) - Most likely given sudden onset, left hemiparesis, sensory loss, and dysarthria 2

2. Intracerebral hemorrhage - Must be excluded urgently given severe hypertension, headache, and vomiting; however, gradual onset and preserved consciousness make this less likely 1

3. Hypertensive encephalopathy - Possible given severe BP elevation, headache, vomiting, and drowsiness, but focal deficits favor stroke 1

4. Posterior reversible encephalopathy syndrome (PRES) - Consider given hypertension and altered mental status, though focal motor deficits are atypical 1

5. Todd's paralysis (post-ictal) - Less likely without witnessed seizure, but cannot be excluded 3

Immediate Next Steps (Within Minutes)

1. Neuroimaging - STAT Priority

• Non-contrast CT head immediately to exclude hemorrhage 2
• CT angiography (CTA) from aortic arch to vertex to identify large vessel occlusion 1
• If CT negative and stroke suspected, MRI with diffusion-weighted imaging (DWI) is superior for detecting acute ischemia 2

2. Laboratory Evaluation - Draw Immediately

• Complete blood count (hemoglobin 11.0, WBC 10.0, platelets 250 already available - no contraindication to thrombolysis) 1
• Coagulation studies (PT/INR, aPTT) - essential before considering thrombolysis 2
• Troponin - to assess for concurrent acute coronary syndrome 1
• Lactate dehydrogenase (LDH) and haptoglobin - to evaluate for thrombotic microangiopathy 1
• Urinalysis with microscopy - to assess renal target organ damage 1

3. Blood Pressure Management - Critical Decision Point

DO NOT lower blood pressure acutely in acute ischemic stroke unless BP >220/120 mmHg. 1 This patient's BP of 200/120 mmHg should be monitored but NOT treated initially, as:

• Lowering BP in acute stroke can worsen cerebral perfusion and extend infarct 1
• If eligible for thrombolysis (tPA), BP must be carefully lowered to <185/110 mmHg and maintained <180/105 mmHg for 24 hours post-treatment 1

If thrombolysis is planned:

• Use IV labetalol 10-20 mg over 1-2 minutes, repeat every 10 minutes to achieve BP <185/110 mmHg 1
• Alternative: IV nicardipine infusion starting at 5 mg/hr, titrate by 2.5 mg/hr every 15 minutes 1

If NOT receiving reperfusion therapy:

• Avoid BP reduction unless BP ≥220/120 mmHg 1
• If treatment needed, reduce BP by approximately 15% over first 24 hours 1

4. Stroke Protocol Activation

• Time of symptom onset is critical - patient was "last seen well" then woke with symptoms, making this a "wake-up stroke" 2
• Thrombolysis window: Standard 4.5-hour window may not apply if exact onset unknown; advanced imaging (MRI with DWI/FLAIR mismatch) may extend eligibility 2
• Mechanical thrombectomy window: Up to 24 hours in selected patients with large vessel occlusion 1

Critical Pitfalls to Avoid

1. DO NOT aggressively lower BP in acute stroke - This is the most common error; BP >220/120 mmHg is the threshold for treatment in ischemic stroke without thrombolysis 1

2. DO NOT use immediate-release nifedipine - Causes unpredictable precipitous BP drops and reflex tachycardia that can worsen cerebral ischemia 1

3. DO NOT delay imaging for laboratory results - CT head should be obtained immediately; labs can be drawn simultaneously 2

4. DO NOT assume this is "just" hypertensive urgency - The presence of acute focal neurologic deficits defines hypertensive emergency requiring ICU admission 1

5. DO NOT overlook wake-up stroke protocols - Advanced imaging may still allow reperfusion therapy even with unknown symptom onset 2

Disposition and Monitoring

• ICU admission mandatory (Class I recommendation) 1
• Continuous arterial line BP monitoring 1
• Continuous cardiac telemetry - to detect atrial fibrillation as stroke etiology 2
• Neurologic checks every 15 minutes initially, then hourly 1
• NPO status until swallow evaluation completed 2

Post-Stabilization Evaluation (After 5-7 Days)

• Screen for secondary hypertension - 20-40% of malignant hypertension has identifiable causes (renal artery stenosis, pheochromocytoma, primary aldosteronism) 1
• Echocardiography - to evaluate for cardioembolic source 2
• Prolonged cardiac monitoring (≥24 hours) - to detect paroxysmal atrial fibrillation 2
• Carotid duplex ultrasonography - to assess for carotid stenosis 2
• Address medication non-compliance - the most common trigger for hypertensive emergencies 1