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Chapter 15: Stroke

A 79-year-old right handed man with a history of hypertension and diabetes presents to emergency department (ED) with sudden onset right-sided hemiplegia and aphasia. His NIHSS is 17. After establishing a last known normal and a brief history, what is the best next step?

A. Obtain a noncontrast CT of the head

B. Administer IV tPA

C. Obtain carotid ultrasound

D. Perform mechanical thrombectomy

A. Obtain a noncontrast CT of the head

The next step after establishing a brief history is obtaining a noncontrast CT of the head to evaluate for an acute hemorrhage or early signs of ischemic stroke. Administering IV tPA (choice B) without a noncontrast head CT is not indicated given the possibility of a hemorrhage. A carotid ultrasound (choice C) is sometimes performed to identify an underlying mechanism and should not be performed during the acute presentation. If the head CT is negative and the patient presented to the hospital within 4.5 hours of initiation of symptoms, IV tPA should still be given regardless of whether a patient is a candidate for mechanical thrombectomy (choice D). Intravenous tPA should not be delayed or deferred while deciding on whether to perform mechanical thrombectomy.

A 69-year-old man with a history of prior strokes and atrial fibrillation on coumadin presents with sudden onset lethargy and left hemiplegia. Noncontrast head CT reveals a large intraparenchymal hemorrhage. What is the next best step?

A. Administer mannitol

B. Obtain CT angiography

C. Place external ventricular drain (EVD) for hydrocephalus

D. Administer prothrombin complex concentrate

D. Administer prothrombin complex concentrate

Reversal of an existing coagulopathy or an anticoagulation agent is the first step in management of patients presenting with an ICH after ensuring stability of airway, breathing, and circulation. Administering mannitol (choice A) can be considered if there is clinical or radiographic signs of impending herniation. An EVD (choice C) can be considered if there is evidence of hydrocephalus on imaging. A CT angiogram (choice B) can identify an underlying vascular malformation resulting in ICH but should not be a priority during the acute presentation.

An 88-year-old man with a history of hypertension, hypercholesterolemia, s/p whipple procedure 5 years ago, diabetes presents to the emergency department with sudden onset of left sided hemiplegia. He regularly takes aspirin. Which of the following is true regarding tPA administration?

A. tPA is contraindicated ...

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