A right-handed, 65-year-old man with a history of hypertension, hyperlipidemia, and atrial fibrillation presents with an acute onset of right-sided weakness, right facial droop, left gaze preference, and aphasia. His family states he was well 20 minutes prior to presenting and that he takes aspirin, lisinopril, and atorvastatin. Vital signs are as follows: BP 193/95 mm Hg, HR 75 beats/min, RR 18 breaths/min, and oxygen saturation 98%. His CT scan shows no acute abnormalities. Which of the following is the priority intervention?
A. Immediate administration of IV rtPA at 0.9 mg/kg
B. Initiate intra-arterial therapy with thrombectomy
C. IV antihypertensive agent to lower the blood pressure to <185/110 mm Hg **
D. Admission to the neuro ICU for conservative medical management
E. Neursurgical decompressive hemicraniectomy and durotomy
** = Your answer
According the American Heart Association/American Stroke Association guidelines for safe administration of IV thrombolysis with rtPA, blood pressure should be controlled to <185/110 mm Hg. Once the blood pressure is controlled and there are no reported contraindications to IV rtPA, the patient should be treated prior to consideration of intra-arterial therapy.
* Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke; a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Feb;47(2):581-641.