A 74-year-old man is rushed to the emergency department with left-sided weakness, facial deviation, and slurred speech. His wife first noticed these changes about an hour ago. The patient is having difficulty communicating. He can answer questions by nodding his head, and his wife is providing detailed information. He denies fever, loss of consciousness, head injury, bleeding, or seizures. Past medical history is significant for diabetes mellitus, hypertension, hyperlipidemia, ischemic heart disease, chronic kidney disease, and osteoarthritis. He had a heart attack 6 weeks ago. Baseline creatinine is 2.5 mg/dL, and he is not on hemodialysis. Medications include aspirin, clopidogrel, metoprolol, ramipril, rosuvastatin, and insulin detemir. Blood pressure is 175/95 mm Hg and the heart rate is 121/min. Muscle strength is decreased in both the upper and lower extremities on the left-side. A forehead sparing left sided facial weakness is also appreciated. An ECG reveals atrial fibrillation. An urgent head CT shows a hypodense area in the right parietal cortex with no indication of hemorrhage. Treatment with tissue plasminogen activator (tPA) is deferred due to which condition?

History of myocardial infarction 6 weeks ago

Atrial fibrillation on electrocardiogram

A 69-year-old male presents to the emergency department for slurred speech and an inability to use his right arm which occurred while he was eating dinner. The patient arrived at the emergency department within one hour. A CT scan was performed of the head and did not reveal any signs of hemorrhage. The patient is given thrombolytics and is then managed on the neurology floor. Three days later, the patient is recovering and is stable. He seems depressed but is doing well with his symptoms gradually improving as compared to his initial presentation. The patient complains of neck pain that has worsened slowly over the past few days for which he is being given ibuprofen. Laboratory values are ordered and return as indicated below: Serum: Na+: 130 mEq/L K+: 3.7 mEq/L Cl-: 100 mEq/L HCO3-: 24 mEq/L Urea nitrogen: 7 mg/dL Glucose: 70 mg/dL Creatinine: 0.9 mg/dL Ca2+: 9.7 mg/dL Urine: Appearance: dark Glucose: negative WBC: 0/hpf Bacterial: none Na+: 320 mEq/L/24 hours His temperature is 99.5°F (37.5°C), pulse is 95/min, blood pressure is 129/70 mmHg, respirations are 10/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?

Continue conservative management

A 77-year-old woman is brought by ambulance to the emergency department after she developed weakness of her right arm along with a right-sided facial droop. By the time the ambulance arrived, she was having difficulty speaking. Past medical history is significant for hypertension, diabetes mellitus type II, and hyperlipidemia. She takes lisinopril, hydrochlorothiazide, metformin, and atorvastatin. On arrival to the emergency department, her vital signs are within normal limits. On physical examination, she is awake and alert but the right side of her mouth is dropping, making it difficult for her to speak clearly. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. Fingerstick glucose is 85 mg/dL. Her right upper extremity strength is 2/5 and her left upper extremity strength is 5/5. Which of the following is the best next step in management?

Obtain noncontrast CT of the brain

Start tissue plasminogen activator (tPA)

A 73-year-old man is brought to the emergency department by ambulance after being found to be non-communicative by his family during dinner. On presentation he appears to be alert, though he is confused and cannot follow instructions. When he tries to speak, he vocalizes a string of fluent but unintelligible syllables. Given this presentation, his physician decides to administer tissue plasminogen activator to this patient. This intervention best represents which of the following principles?

This does not represent prevention

A 77-year-old man with a history of hypertension and a 46 pack-year smoking history presents to the emergency department from an extended care facility with acute onset of headache, nausea, vomiting, and neck pain which started 6 hours ago and has persisted since. He is alert, but his baseline level of consciousness is slightly diminished per the nursing home staff. His temperature is 99.0°F (37.2°C), blood pressure is 164/94 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 98% on room air. The patient's neurological exam is unremarkable with cranial nerves II-XII grossly intact and with stable gait with a walker. He is immediately sent for a head CT which is normal. What is the most appropriate next step in management?

Ibuprofen, acetaminophen, metoclopramide, and diphenhydramine

A 27-year-old man presents to the emergency department with dizziness. He states he has experienced a sustained sensation of the room spinning that is low grade and constant since this morning. The patient occasionally feels nauseous and has been taking diphenydramine to sleep which helps with his symptoms. The patient is generally healthy, has no other medical conditions, and only endorses eating more garlic recently to get over a cold he had a few days ago. His temperature is 98.7°F (37.1°C), blood pressure is 122/81 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for a healthy man. The patient is sat upright, his head is turned slightly to the right, and he is laid back flat rapidly. This does not provoke any symptoms even when repeated on the left side. A nystagmus is notable on cranial nerve exam as well as bilateral decreased hearing. The patient’s tandem gait is unstable; however, his baseline gait appears unremarkable despite the patient stating he has a sustained sensation of imbalance. Which of the following is the most likely diagnosis?

Benign paroxysmal positional vertigo

Acute ischemic stroke management — USMLE Lesson

Initial Assessment - Time is Brain!

Priority #1: Stabilize patient (ABCs), establish IV access, and get vital signs.
ASAP Actions:
- Finger-stick glucose to rule out hypoglycemia (a key stroke mimic).
- Focused history: Pinpoint "Last Known Well" (LKW) time.
- Baseline neurologic exam using the NIH Stroke Scale (NIHSS).
Crucial Diagnostic: Immediate non-contrast head CT to differentiate ischemic vs. hemorrhagic stroke. This dictates all subsequent therapy.

Non-contrast CT: Normal brain vs. hyperacute ischemic stroke

⭐ The single most important initial imaging study for a suspected stroke patient is a non-contrast head CT to rule out intracranial hemorrhage before considering thrombolysis.

IV Thrombolysis - Clot Buster Crew

Drug: Alteplase (tPA), a recombinant tissue plasminogen activator.
Mechanism: Converts plasminogen to plasmin → degrades fibrin clot.
Time Window: Crucial! Administer within 3 to 4.5 hours of "last known well" time.

Key Criteria:

Inclusion: Disabling ischemic stroke, age >18.
Exclusion (Common):
- BP > 185/110 mmHg (refractory to treatment).
- Active bleed, recent major surgery/trauma (<3 months).
- Platelets <100,000, INR >1.7.
- History of intracranial hemorrhage.

⭐ Blood pressure control is critical. BP must be < 185/110 mmHg before starting and maintained < 180/105 mmHg for 24h after infusion. Use IV Labetalol or Nicardipine.

Endovascular Therapy - The Clot Claw

Indication: Mechanical thrombectomy for Large Vessel Occlusion (LVO) in the anterior circulation (e.g., ICA, MCA-M1).
Time Window:
- Standard: Within 6 hours of symptom onset.
- Extended: Up to 24 hours if DAWN or DEFUSE-3 trial criteria are met.
Core Criteria:
- Pre-stroke mRS 0-1.
- NIHSS ≥ 6.
- Alberta Stroke Program Early CT Score (ASPECTS) ≥ 6.

Endovascular thrombectomy for acute ischemic stroke

⭐ The key to the extended 6-24 hour window is imaging-based selection. A significant mismatch between a small, irreversible infarct core and a large, salvageable penumbra on CT perfusion or MRI justifies intervention.

Supportive Care - Pressure & Prevention

Blood Pressure Control: Crucial to balance perfusion & hemorrhage risk.

DVT Prophylaxis:
- Start intermittent pneumatic compression (IPC) devices immediately.
- Delay subcutaneous heparin/LMWH for 24h post-thrombolysis.
Aspiration Prevention:
- Keep patient NPO (nil per os) initially.
- Perform a formal swallow screen before allowing any oral intake.

⭐ Permissive Hypertension: In patients not receiving thrombolysis, higher blood pressure is tolerated to maintain cerebral perfusion to the ischemic penumbra. Aggressively lowering BP can worsen the stroke.

High‑Yield Points - ⚡ Biggest Takeaways

Time is brain: A non-contrast CT is crucial to rule out hemorrhage before any intervention.

IV alteplase (tPA) is the standard of care if administered within 3 to 4.5 hours of symptom onset, assuming no contraindications.

Mechanical thrombectomy is indicated for large vessel occlusions (LVO) with a treatment window of up to 24 hours.

Blood pressure must be <185/110 mmHg before tPA. Otherwise, permissive hypertension is generally allowed.

Initiate aspirin within 24-48 hours, but delay for 24 hours if the patient received tPA.

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