A 68-year-old man is brought to the emergency department by his wife due to the sudden onset of right-sided weakness and difficulty speaking. His symptoms began approximately 6 hours ago. He has a history of type 2 diabetes mellitus and hyperlipidemia. His blood pressure is 210/115 mmHg, heart rate is 88/min, and respiratory rate is 16/min. Neurological examination reveals a dense right-sided hemiparesis and expressive aphasia. A non-contrast CT scan of the head is negative for intracranial hemorrhage or early signs of a large-territory infarct.
Which of the following is the most appropriate next step in the management of this patient’s blood pressure?
The correct answer is:
A) Aspirin and clinical monitoring.
This patient is presenting with an acute ischemic stroke (AIS). Because his symptoms began 6 hours ago, he is outside the standard 4.5-hour window for intravenous thrombolysis with alteplase. In patients with AIS who are not candidates for thrombolytic therapy, permissive hypertension is recommended. This involves withholding antihypertensive therapy unless the blood pressure is extreme (systolic > 220 mmHg or diastolic > 120 mmHg) or there is evidence of other end-organ damage (e.g., aortic dissection, acute myocardial infarction, heart failure). This patient’s blood pressure of 210/115 mmHg does not meet the threshold for intervention. Maintaining a higher blood pressure helps maximize collateral blood flow to the ischemic penumbra which is the salvageable brain tissue surrounding the core of the infarct. Aspirin is the appropriate immediate pharmacologic intervention for secondary prevention.
Answer choice B: Intravenous alteplase, is incorrect. The window for intravenous thrombolysis is generally within 3 to 4.5 hours of symptom onset. Since this patient’s symptoms began 6 hours ago, the risks of hemorrhagic transformation outweigh the benefits of alteplase.
Answer choice C: Intravenous labetalol, is incorrect. While labetalol is a first-line agent for blood pressure control in acute stroke, it is not indicated here because the patient's blood pressure is below the 220/120 mmHg threshold for those not receiving thrombolytics. Lowering the blood pressure could potentially worsen the stroke by decreasing perfusion to the ischemic penumbra.
Answer choice D: Intravenous nicardipine, is incorrect. Like labetalol, nicardipine is a preferred agent for rapid blood pressure titration in stroke, but it should be reserved for patients with a blood pressure > 220/120 mmHg or those undergoing thrombolysis with a blood pressure > 185/110 mmHg.
Answer choice E: Oral lisinopril, is incorrect. ACE inhibitors are part of long-term secondary prevention for stroke, but they are not used in the acute management phase. Furthermore, oral medications are generally avoided in the hyperacute phase of stroke if there is a concern for dysphagia or if rapid titration of blood pressure is required.
Key Learning Point
In the management of acute ischemic stroke, permissive hypertension is used to maintain cerebral perfusion to salvageable brain tissue. For patients who are not candidates for thrombolytic therapy, blood pressure should not be lowered unless it exceeds 220/120 mmHg. For patients who are candidates for thrombolysis, the blood pressure must be maintained below 185/110 mmHg.
