What is the acute management for a 48‑year‑old woman with hypertension, pre‑diabetes, prior mild stroke, on clopidogrel, atorvastatin, nebivolol and pregabalin, who presents with acute right‑sided motor weakness (2/5 strength) after a severe headache, numbness and chills, with a normal Glasgow Coma Scale and no sensory deficits?

Acute Management of Suspected Ischemic Stroke with Right-Sided Weakness

Immediate Priorities (Within Minutes)

This patient requires emergency brain imaging (CT or MRI) immediately to exclude hemorrhage and confirm ischemic stroke, followed by consideration for thrombolytic therapy if within the treatment window. 1, 2

Critical Time-Sensitive Assessment

• Establish time of symptom onset – the patient's "last known well" time determines thrombolytic eligibility (must be within 3-4 hours for IV tPA). 3 The severe headache followed by right-sided weakness defines the onset window.

• Obtain emergency non-contrast CT brain to exclude hemorrhage before any antithrombotic therapy. 3 Given the history of prior stroke and current antiplatelet therapy, hemorrhagic transformation is a critical consideration.

• Complete NIHSS scoring to quantify stroke severity and guide treatment decisions. 3 The documented 2/5 strength in right upper and lower extremities suggests moderate-to-severe deficit.

• Rule out stroke mimics – the blood glucose of 130 mg/dL excludes hypoglycemia, but seizure (Todd's paralysis) should be considered given the acute presentation. 3

Blood Pressure Management

Do NOT lower this patient's blood pressure acutely unless it exceeds 220/120 mmHg, as premature reduction can worsen cerebral perfusion and expand the infarct. 3, 1, 2

Blood Pressure Targets

• If NOT receiving thrombolysis: Withhold antihypertensive agents unless systolic BP >220 mmHg or diastolic BP >120 mmHg. 3, 1, 2 The transient BP elevation represents the body's compensatory response to maintain collateral flow to the penumbra.

• If eligible for thrombolysis: Blood pressure must be reduced to <185/110 mmHg before initiating tPA, then maintained ≤180/105 mmHg for at least 24 hours post-thrombolysis. 3, 1, 2

Preferred Antihypertensive Agents (If Required)

• Labetalol 10-20 mg IV over 1-2 minutes, repeat or double every 10-20 minutes to maximum 300 mg. 3, 1, 2 Labetalol is preferred because it preserves cerebral blood flow and does not increase intracranial pressure.

• Nicardipine 5 mg/hr IV infusion, titrate by 2.5 mg/hr every 5-15 minutes to maximum 15 mg/hr. 3, 1, 2 Nicardipine is an excellent alternative with predictable titration.

• Avoid sublingual nifedipine due to risk of precipitous BP drops that can worsen cerebral ischemia. 3, 2

Blood Pressure Monitoring Protocol

• Every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours if thrombolysis is administered. 3, 2

• Continuous arterial line monitoring is NOT required for ischemic stroke unless the patient develops hypertensive emergency with other organ damage. 1, 4

Glycemic Management

Monitor blood glucose every 1-2 hours for the first 24-48 hours, especially if the patient receives thrombolytic therapy, as hyperglycemia >140 mg/dL increases risk of hemorrhagic transformation. 3

• Treat hyperglycemia if glucose >140 mg/dL, particularly in thrombolysis candidates, using hospital insulin protocols. 3 The current glucose of 130 mg/dL is acceptable but requires ongoing monitoring.

• Correct hypoglycemia immediately with 1 ampule of 50% dextrose if glucose drops, as hypoglycemia can mimic or worsen stroke deficits. 3

• Avoid intensive euglycemic protocols (targeting 4-7 mmol/L) as they have not shown mortality benefit and may increase hypoglycemia risk. 3

Antiplatelet Therapy

Aspirin 150-300 mg should be given as soon as possible after CT excludes hemorrhage, ideally within 48 hours of symptom onset. 3

• Continue clopidogrel after the acute phase, as the patient has a history of prior stroke and is already on dual antiplatelet therapy. 3, 5 However, do NOT administer aspirin until hemorrhage is excluded.

• Do NOT use anticoagulation (unfractionated heparin, LMWH) routinely in acute ischemic stroke, as it does not improve outcomes and increases bleeding risk. 3

• Note potential drug interaction: The patient is on atorvastatin, which may theoretically reduce clopidogrel's antiplatelet effect via CYP3A4 competition. 6, 7, 8 However, large clinical trials (CREDO, TRITON-TIMI 38) found no clinically significant adverse interaction, so continue both medications. 6, 8

Physiological Monitoring

Continuous monitoring of neurological status (GCS, NIHSS), vital signs (pulse, BP, temperature, oxygen saturation), and respiratory pattern is essential during the acute phase. 3

• Oxygen supplementation only if SpO₂ <90%, as routine oxygen in non-hypoxic patients does not improve outcomes. 3

• Monitor for cerebral edema starting at 24-48 hours post-stroke, with peak risk at 3-5 days. 3 Early signs include declining level of consciousness; late signs include pupillary changes.

• Assess for increased intracranial pressure if the patient develops worsening headache, declining consciousness, new pupillary changes, or respiratory pattern changes. 3

Swallowing and Nutrition

Screen for dysphagia before giving any oral intake (food, drink, or medications) using personnel trained in swallowing screening, ideally within 24 hours of admission. 3

• Keep patient NPO until swallowing screen is completed. 3 If the patient fails screening, refer to speech pathology for comprehensive assessment.

• Nasogastric feeding is the preferred method during the first month if dysphagia persists. 3

• Monitor hydration status closely and provide appropriate IV fluid supplementation to prevent dehydration, which can worsen outcomes. 3

Early Mobilization

Mobilize the patient as early and as frequently as possible after initial stabilization, following physiotherapist assessment. 3

Surgical Considerations

For patients 18-60 years with significant middle cerebral artery infarction, urgent neurosurgical consultation for hemicraniectomy should occur if surgery can be performed within 48 hours of symptom onset. 3 This patient at age 48 falls within this window if imaging demonstrates large MCA territory infarction.

Critical Pitfalls to Avoid

• Do NOT aggressively lower blood pressure in acute ischemic stroke unless >220/120 mmHg or the patient is receiving thrombolysis. 3, 1, 2 Premature BP reduction can extend the infarct by reducing collateral perfusion.

• Do NOT give aspirin before CT excludes hemorrhage. 3

• Do NOT use routine anticoagulation in unselected acute ischemic stroke patients. 3

• Do NOT allow oral intake before swallowing screening, as aspiration pneumonia significantly worsens stroke outcomes. 3

• Do NOT dismiss the patient's pre-diabetes and hypertension – these are major stroke risk factors requiring aggressive secondary prevention after the acute phase. 3, 5