WBR0896

Author	[[PageAuthor::Ayokunle Olubaniyi, M.B,B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Neurology
Prompt	[[Prompt::A 66-year-old woman with a past medical history of hypertension, osteoarthritis, and depression is brought to the ED with an acute onset of impaired speech, right-sided hemiplegia, and right-sided facial palsy. She suddenly noticed that she was unable to use her right arm and leg 2 hours ago. There is history of a prior stroke 2 months ago. She also complains of headache and dizziness. No history of trauma. She is on hydrochlorothiazide, lisinopril, pravastatin, and warfarin. For the past two months, her diet has been restricted to vegetables and an herbal tea which helps with her depression. Her vitals reveals a temperature of 38.5 degree Celsius, blood pressure of 200/112 mmHg, heart rate of 105 beats per minute, respiratory rate of 12 breaths per minute, and she is saturating at 92%, while breathing room air. Examination reveals an elderly woman, conscious and alert, not in any obvious painful distress. Lungs and cardiac were auscultations are unremarkable. Abdomen was non-tender, non-distended and without any hepatosplenomegaly. Neurological examination confirms the presenting complaints above. An immediate non-contrast CT of the brain done ruled out hemorrhage in the brain. You are strongly considering the use of intravenous recombinant TPA (alteplase) in this patient. What is the next step in the management of this patient?]]
Answer A	AnswerA::Administer IV recombinant TPA (alteplase) and transfer the patient to ICU for BP monitoring.
Answer A Explanation	AnswerAExp::Thrombolysis is contraindicated in this patient.
Answer B	AnswerB::Administer IV labetalol to control the blood pressure.
Answer B Explanation	[[AnswerBExp::Elevated blood pressure is generally not treated until it is >220/120 mmHg, or when BP is <220/120 mmHg with evidence of end organ damage (e.g., myocardial infarction, aortic dissection, pulmonary edema, and hypertensive encephalopathy).]]
Answer C	AnswerC::Transfer the patient to ICU for close monitoring of blood pressure and manage conservatively.
Answer C Explanation	AnswerCExp::Conservative management is indicated in this patient.
Answer D	AnswerD::Administer ASA 325 mg and manage conservatively.
Answer D Explanation	AnswerDExp::A follow-up CT/MRI and speech and swallow evaluation are indicated before oral treatment can be initiated. Furthermore, all forms of anticoagulation are contraindicated in the first 24 hours of symptom onset.
Answer E	AnswerE::Treat fever with oral acetaminophen
Answer E Explanation	AnswerEExp::Fever may be managed with IV acetaminophen, but oral medications cannot be administered.
Right Answer	RightAnswer::C
Explanation	[[Explanation::This is a case of acute ischemic stroke. There was a history of stroke 2 months prior to presentation. The present stroke, despite anticoagulation with warfarin, may be explained by the intake of st. John’s wort (the herbal tea) which is known to increase the metabolism of warfarin, thereby reducing its anticoagulant actions. The presence of a prior stroke less than 3 months ago, current intake of warfarin, and an elevated BP>180/110 mmHg makes the patient an unsuitable candidate for thrombolysis. Conservative management is usually indicated in the management of patients with an acute ischemic stroke ineligible for thrombolysis within the first 24 hours. In patients with contraindication to thrombolysis, elevated blood pressure is generally not treated until it is >220/120 mmHg, or when BP is <220/120 mmHg with evidence of end organ damage (e.g., myocardial infarction, aortic dissection, pulmonary edema, and hypertensive encephalopathy). The exclusion criteria for IV rTPA administration must be reviewed carefully before thrombolysis. They are: Exclusion Criteria for IV Recombinant TPA Treatment Less than 3 hours of onset Significant head trauma or prior stroke in previous 3 months Symptoms suggest subarachnoid hemorrhage Arterial puncture at noncompressible site in previous 7 days History of previous intracranial hemorrhage Intracranial neoplasm, arteriovenous malformation, or aneurysm Recent intracranial or intraspinal surgery Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg) Active internal bleeding Acute bleeding diathesis, including but not limited to Platelet count <100,000/mm³ Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the upper limit of normal Current use of anticoagulant with INR >1.7 or PT >15 seconds Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa activity assays) Blood glucose concentration <50 mg/dL (2.7 mmol/L) CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere) Relative exclusion criteria Only minor or rapidly improving stroke symptoms (clearing spontaneously) Pregnancy Seizure at onset with postictal residual neurological impairments Major surgery or serious trauma within previous 14 days Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days) Recent acute myocardial infarction (within previous 3 months) Between 3 and 4.5 hours of onset Aged >80 years Severe stroke (NIHSS>25) Taking an oral anticoagulant regardless of INR History of both diabetes and prior ischemic stroke Educational Objective: Patients with acute ischemic stroke, who also have contraindications to thrombolysis treatment, are best managed conservatively within the first 24 hours of symptom onset. Elevated blood pressure is generally not treated until it is >220/120 mmHg, or when BP is <220/120 mmHg with evidence of end organ damage (e.g., myocardial infarction, aortic dissection, pulmonary edema, and hypertensive encephalopathy). Reference: http://www.wikidoc.org/index.php/Stroke_resident_survival_guide Educational Objective: References: ]]
Approved	Approved::No
Keyword	WBRKeyword::Acute ischemic stroke, WBRKeyword::thrombolysis in stroke
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