Should a stroke code be activated and is the patient a candidate for tissue plasminogen activator (tPA) or a stat computed tomography (CT) head given worsening left hemiparesis 3 weeks after an ischemic stroke?

Immediate Management of Worsening Hemiparesis 3 Weeks Post-Stroke

Activate a stroke code immediately and obtain a stat CT head, but this patient is NOT a candidate for tPA due to being far beyond the therapeutic window. 1

Why tPA is Contraindicated

Intravenous tPA is only proven effective within 3 hours of symptom onset, and is not of proven benefit beyond this window. 1 The patient's worsening symptoms occurred 3 weeks after the initial stroke, placing them well outside any therapeutic window for thrombolytic therapy. 1

• The FDA-approved treatment window for IV tPA is within 3 hours of stroke onset, with extended use up to 4.5 hours in select patients having additional exclusion criteria. 2
• Beyond 3 hours, IV tPA is best contemplated only in clinical trial settings, regardless of CT findings. 1
• The NINDS trial demonstrated benefit only when treatment was initiated within 180 minutes, with optimal outcomes when given within 90 minutes. 1

Critical Immediate Actions Required

Stat CT Head is Mandatory

Obtain emergent non-contrast CT head to identify the cause of clinical deterioration. 1 Brain imaging is required to guide acute intervention and must be performed immediately. 1

The differential diagnosis for worsening 3 weeks post-stroke includes:

• Hemorrhagic transformation of the original infarct - occurs in up to 40% of large infarcts and peaks at 1-2 weeks but can occur up to 3-4 weeks post-stroke 3
• New ischemic stroke - recurrent embolization or new vascular territory involvement 3
• Brain edema with mass effect - typically peaks at 3-5 days but can cause delayed deterioration 3
• Seizures - post-stroke seizures occur in 5-20% of patients and can cause transient worsening 3
• Systemic complications - infection, metabolic derangements, or medication effects 3

Activate Stroke Code Protocol

Yes, activate the stroke code to mobilize rapid multidisciplinary evaluation. 1 Even though tPA is contraindicated, stroke code activation ensures:

• Immediate neurological assessment with NIHSS scoring 1
• Rapid CT imaging with skilled interpretation available 1
• Vascular imaging (CTA or MRA) to assess for large vessel occlusion if new stroke is suspected 1
• Blood pressure management protocols 1
• Consideration for alternative interventions if indicated 3

Blood Pressure Management is Critical

Maintain systolic BP <180 mmHg and diastolic <105 mmHg to prevent hemorrhagic transformation of established infarct. 4 In patients with recent ischemic stroke and worsening symptoms:

• Avoid excessive BP reduction that could compromise collateral perfusion to penumbral tissue 1, 4
• If systolic BP ≥220 mmHg or diastolic 120-140 mmHg, cautiously reduce by 10-15% while monitoring for neurological deterioration 1
• If diastolic ≥140 mmHg, use carefully monitored sodium nitroprusside infusion 1

Potential Therapeutic Options Based on Imaging

If New Ischemic Stroke is Identified

• Consider endovascular thrombectomy if large vessel occlusion is present, as mechanical thrombectomy has extended time windows (up to 24 hours in select patients with favorable imaging) 3
• Initiate or optimize antiplatelet therapy after excluding hemorrhage 4
• Evaluate for cardioembolic source requiring anticoagulation 4

If Hemorrhagic Transformation is Present

• Reverse any anticoagulation immediately 2
• Strict BP control to prevent hematoma expansion 1, 4
• Neurosurgical consultation if significant mass effect 3

If Cerebral Edema with Mass Effect

• Consider decompressive hemicraniectomy for malignant MCA infarction with life-threatening edema 3
• Osmotic therapy with mannitol or hypertonic saline 3
• Elevate head of bed to 30 degrees 3

Common Pitfalls to Avoid

Do not delay imaging while attempting to determine exact time of symptom worsening - the priority is identifying the cause of deterioration, not calculating eligibility for tPA which is already excluded by the 3-week timeline. 1

Do not assume this is simply "stroke progression" - up to one-third of stroke patients worsen after admission, and most causes are treatable if identified promptly. 3 The differential includes hemorrhagic transformation, new stroke, seizures, and systemic complications, each requiring different management. 3

Do not withhold stroke code activation based on the remote timing of initial stroke - the acute change in neurological status warrants emergent evaluation regardless of when the index event occurred. 1