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Question 4#

A 71-year-old woman is brought to the emergency room by her daughter because of sudden onset of right-sided weakness and slurred speech. The patient, a recent immigrant from Southeast Asia, has not seen a doctor in two decades. Her symptoms began 75 minutes ago while she was eating breakfast. A stat noncontrast CT scan of the head is normal. Labs are normal. Physical examination reveals an anxious appearing woman with dense hemiplegia of the R upper and lower extremities. Deep tendon reflexes are not discernible on the R side and 2+ on the left. Aspirin has been given. What is the best next step in management of this patient?

A) Immediate intravenous unfractionated heparin
B) Immediate thrombolytic therapy
C) Immediate administration of interferon-beta
D) Emergent MRI/MRA of head
E) Emergent cardiac catheterization

Correct Answer is B

Comment:

 This patient presents with an acute left middle cerebral artery stroke. Time is of the essence if thrombolytic therapy is to be beneficial. Intravenous thrombolytics may be administered up to 3 hours after the onset of symptoms. Recent studies have suggested expanding the window of opportunity to 4.5 hours. Fortunately, this patient was brought to the ER promptly. CT scan of the brain shows no evidence of bleed. Evidence of ischemia may not become apparent until 48 to 72 hours. A prior history of intracranial hemorrhage, recent surgery, bleeding diathesis, onset of symptoms greater than 3 to 4.5 hours prior to therapy, and unknown time of onset of symptoms are contraindications to thrombolytic therapy. This patient should be given intravenous tissue-type plasminogen activator (t-PA). Anticoagulation in acute stroke (answer a) is not currently recommended. In most trials of anticoagulation, any benefit of therapy is matched by an increase in hemorrhagic transformation. Interferon-beta (answer c) is used to treat multiple sclerosis, not ischemic stroke. Emergent scanning with MRI (answer d) wastes precious time and is not always available. Patients with acute stroke often have mild elevation in cardiac biomarkers. Cardiac catheterization (answer e) is unnecessary, and may very well prove harmful in the setting of a stroke.