What can I administer to a patient with suspected acute pontine infarction (stroke) in an outpatient department (OPD) setting while referring them to a neurologist?

Immediate Management of Suspected Acute Pontine Infarction in OPD Setting

In an outpatient setting with suspected acute pontine stroke, immediately administer aspirin 160-325 mg to chew (if no contraindications) and arrange urgent transfer to a stroke center emergency department—do not attempt further management in the OPD. 1, 2

Critical First Steps

Immediate Actions Before Transfer

• Administer aspirin 160-325 mg (non-enteric) to chew if the patient has not taken aspirin, has no aspirin allergy, and no evidence of recent gastrointestinal bleeding 1, 3
• Provide supplementary oxygen only if oxygen saturation is <94% or unknown 1, 2
• Do NOT attempt to lower blood pressure unless systolic BP is >220 mmHg or diastolic >120 mmHg—prehospital blood pressure intervention is contraindicated unless the patient is hypotensive (systolic <90 mmHg) 1
• Keep patient NPO (nothing by mouth) until swallowing can be assessed, as pontine strokes frequently cause dysphagia 1, 2

What NOT to Do in OPD

• Do not delay transfer to obtain extensive workup or imaging in the outpatient setting 2, 4
• Do not administer anticoagulants (heparin, warfarin) in the acute setting 1
• Do not give IV beta-blockers, nitroglycerin, or other cardiovascular medications unless specifically treating severe hypertension or tachyarrhythmias 1
• Do not position patient flat if there is any concern for aspiration risk; elevate head of bed 25-30 degrees 1

Essential Information to Document and Communicate

Time-Critical Information

• Establish and document the exact time the patient was last at their previous baseline or symptom-free (this determines thrombolytic eligibility, not when symptoms were discovered) 1, 2
• Document current NIHSS score or at minimum: level of consciousness, motor strength in all limbs, speech/dysarthria, ataxia, and any cranial nerve deficits 2, 4

Clinical Features Suggesting Pontine Infarction

Pontine infarctions typically present with combinations of: motor deficits with dysarthria and ataxia (58% anteromedial pattern), motor-sensory deficits with tegmental signs like eye movement disorders (17% anterolateral pattern), or isolated tegmental syndrome with vertigo and mild motor deficits (10%) 5. Document specifically: presence of crossed signs (ipsilateral cranial nerve with contralateral motor/sensory), dysarthria, ataxia, vertigo, diplopia, or facial weakness 5.

Urgent Referral Protocol

Call Ahead to Stroke Center

• Notify receiving hospital that a suspected stroke patient is being transferred, providing time of symptom onset and current deficits 1
• Request direct triage to stroke center rather than general emergency department if available 1, 4
• Arrange ambulance transport rather than private vehicle—EMS can provide monitoring and expedite ED evaluation 4

Critical Contraindications to Aspirin

Do not give aspirin if: platelet count <100,000/mm³ (if known), current anticoagulation use, known aspirin allergy, active bleeding, or recent gastrointestinal/urinary hemorrhage within 21 days 1

Why This Matters

Time is brain: Patients presenting within 4.5 hours may be eligible for IV thrombolysis, and those within 6-24 hours may qualify for endovascular thrombectomy 1, 2. Early aspirin administration (within 48 hours) prevents approximately 10 deaths and recurrent strokes per 1,000 patients treated 6, 7. Pontine infarctions carry a 28% risk of early neurological deterioration within the first week, making urgent specialist evaluation essential 8, 9.

The OPD is not equipped for the rapid imaging (CT/CTA within minutes), laboratory assessment (INR, aPTT, platelet count, glucose), and time-sensitive interventions required for acute stroke management 1, 2. Even a delay of 30-60 minutes in an outpatient setting can eliminate thrombolytic eligibility.