A patient presents with acute right‑hand weakness, intermittent dysarthria, blood pressure 150/110 mm Hg, pulse 64 bpm, and SpO₂ 99% on room air. What is the most likely diagnosis and emergent management?

Acute Ischemic Stroke with Permissive Hypertension

This patient is experiencing an acute ischemic stroke (right hand weakness with intermittent dysarthria), and the blood pressure of 150/110 mmHg should NOT be treated—this represents appropriate permissive hypertension that supports cerebral perfusion to the ischemic penumbra. 1, 2

Immediate Diagnostic Priorities

Establish the exact time the patient was last known to be neurologically normal (not when symptoms were first noticed)—this "last known well" time determines eligibility for IV thrombolysis (rtPA), which must be given within 4.5 hours of onset. 1, 3

Critical Initial Assessment

• Perform NIH Stroke Scale (NIHSS) to quantify stroke severity and document baseline neurological function 1, 4
• Obtain emergent non-contrast head CT within 25 minutes of arrival to exclude hemorrhage and assess for early ischemic changes 1, 3
• Measure blood pressure in both arms—aortic dissection can present with stroke and unilateral weakness, and dissection-related branch vessel occlusion may cause falsely low readings in the affected limb 1, 2
• Obtain immediate blood work: glucose, complete blood count, coagulation studies (INR, aPTT), creatinine, electrolytes 1, 3
• Initiate cardiac monitoring to detect atrial fibrillation or life-threatening arrhythmias 1, 3

Blood Pressure Management Strategy

For Patients NOT Receiving Thrombolysis

Do not initiate or restart antihypertensive medications when systolic BP is <220 mmHg or diastolic <120 mmHg during the first 48-72 hours. 1, 2 This patient's BP of 150/110 mmHg falls well below this threshold.

Physiologic rationale: Cerebral autoregulation is impaired in the ischemic penumbra, making cerebral blood flow directly dependent on systemic perfusion pressure—lowering BP can extend the infarct by reducing flow to potentially salvageable brain tissue. 1, 2, 3

The observational data show a U-shaped relationship between admission BP and outcomes, with optimal systolic BP ranging from 121-200 mmHg. 2 This patient's systolic of 150 mmHg is within the optimal range.

For Patients Receiving IV Thrombolysis (rtPA)

If the patient is within the treatment window and eligible for rtPA:

• Before rtPA: BP must be lowered to <185/110 mmHg 1, 2
• After rtPA: Maintain BP <180/105 mmHg for at least 24 hours 1, 2
• Monitoring schedule: Every 15 minutes × 2 hours, then every 30 minutes × 6 hours, then hourly × 16 hours 1, 2

Preferred agents for BP control:

• Labetalol: 10-20 mg IV bolus over 1-2 minutes (may repeat) or continuous infusion 2-8 mg/min 1, 2, 4
• Nicardipine: 5 mg/hr IV, titrate by 2.5 mg/hr every 5-15 minutes, maximum 15 mg/hr 1, 2, 4

Differential Diagnosis Considerations

Right hemispheric stroke is most likely given right hand weakness and dysarthria. 1 The intermittent nature of the dysarthria suggests fluctuating perfusion in the ischemic territory.

Rule out aortic dissection urgently—the combination of neurological symptoms with hypertension (150/110 mmHg) and relative bradycardia (pulse 64) raises concern. 1 Dissection can present with stroke in 17% of cases, predominantly affecting the right hemisphere. 1 Measure BP in both arms and both legs if needed to detect pressure differentials. 1

Exclude stroke mimics: seizure with Todd's paralysis, brain tumor, or migrainous aura. 1, 3

Critical Management Pitfalls to Avoid

• Do NOT lower this patient's BP of 150/110 mmHg unless thrombolysis is planned—studies show that initiating antihypertensive therapy at systolic >180 mmHg in the acute phase is associated with marked increases in early deterioration, poor neurological outcome, and death. 3
• Avoid sublingual nifedipine or any agent causing precipitous BP drops—these cannot be titrated and may catastrophically compromise cerebral perfusion. 2, 3
• Do NOT restart home antihypertensives during the first 48-72 hours unless the patient receives reperfusion therapy. 1, 2

Urgent Exceptions Requiring Immediate BP Control

Override permissive hypertension guidelines and treat BP immediately if:

• Hypertensive encephalopathy
• Acute aortic dissection
• Acute myocardial infarction
• Acute pulmonary edema
• Acute renal failure

1, 2, 4

Post-Acute Management (After 48-72 Hours)

Restart antihypertensive therapy in neurologically stable patients when BP ≥140/90 mmHg for long-term secondary stroke prevention, targeting <130/80 mmHg with thiazide diuretics, ACE inhibitors, or ARBs. 2, 3