A 72-year-old man is brought to the emergency department by his daughter because of the sudden onset of right-sided weakness and a facial droop that began 2 hours ago. He has a history of hypertension, hyperlipidemia, and a hemorrhagic stroke 5 years ago that resulted in temporary left-sided numbness. His current medications include lisinopril and atorvastatin. His blood pressure is 174/96 mmHg and his heart rate is 82/min. Neurological examination reveals a right-sided facial palsy and 2/5 strength in the right upper and lower extremities. A non-contrast CT scan of the head shows no evidence of intracranial hemorrhage or early ischemic changes.
Which of the following is the most appropriate next step in the management of this patient?
The correct answer is:
A) Aspirin
The patient is presenting with an acute ischemic stroke (AIS) within the 3- to 4.5-hour window for thrombolytic therapy. However, he has an absolute contraindication to intravenous alteplase because of his history of prior intracranial hemorrhage. Other absolute contraindications include active internal bleeding, recent intracranial or intraspinal surgery/trauma (within 3 months), intracranial neoplasm, arteriovenous malformation, or aneurysm, and current severe uncontrolled hypertension (>185/110 mmHg). Because he is not a candidate for thrombolysis, the most appropriate next step is the administration of aspirin (usually 160–325 mg) for secondary prevention and acute management.
Answer choice B: Clopidogrel, is incorrect. While clopidogrel is an antiplatelet agent used for secondary stroke prevention, it is not the first-line agent for acute management of an ischemic stroke in the emergency setting. Aspirin is the standard of care for acute antiplatelet therapy unless a specific contraindication to aspirin exists.
Answer choice C: Intravenous alteplase, is incorrect. Although the patient is within the time window for thrombolysis, his history of a prior hemorrhagic stroke is an absolute contraindication to the administration of alteplase due to the significantly increased risk of recurrent intracranial hemorrhage.
Answer choice D: Intravenous heparin, is incorrect. Heparin and other systemic anticoagulants have not been shown to improve outcomes in the hyperacute management of ischemic stroke and are associated with an increased risk of hemorrhagic transformation. They are generally avoided in the first 24 hours of stroke management.
Answer choice E: Intravenous labetalol, is incorrect. This patient's blood pressure is 174/96 mmHg. In patients with acute ischemic stroke who are not candidates for thrombolysis, antihypertensive therapy like labetalol is typically withheld unless the blood pressure exceeds 220/120 mmHg, an approach called permissive hypertension. Lowering the blood pressure unnecessarily can decrease perfusion to the ischemic penumbra.
Key Learning Point
Absolute contraindications to intravenous alteplase in acute ischemic stroke include a history of prior intracranial hemorrhage, active internal bleeding, recent (within 3 months) intracranial or intraspinal surgery or serious head trauma, and the presence of intracranial conditions that increase bleeding risk (e.g., certain neoplasms, aneurysms).
