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NEUROSAE 2018 ANNUAL MEETING EDITION (VOLUME 10, ISSUE 3)
QUESTION 82 OF 100
A right-handed, 66-year-old man presents with acute aphasia and right-sided hemiplegia within 2 hours of symptom onset. He has a history of paroxysmal atrial fibrillation and takes warfarin with subtherapeutic INR. A noncontrast head CT scan is unremarkable for acute abnormality. The patient receives IV thrombolysis within 3 hours of symptom onset. Once the infusion is complete, his NIH Stroke Scale score is 9. What is the next best step in management?
A. Initiation of an IV osmotic agent to control brain swelling
B. Consult with neurosurgery for hemicraniectomy watch
C. CT angiography and consideration for possible mechanical thrombectomy
D. MRI of the brain to assess the extent of the acute infarct
E. Repeat noncontrast head CT to rule out intracranial bleeding **
** = Your answer
The degree and type of stroke this patient experienced is clearly disabling. Aphasia is a cortical symptom, suggesting ischemia in the left middle cerebral artery territory. Proximal vessel occlusion is less likely to respond IV thrombolysis alone. Four recent randomized trials reported clot retrieval plus IV thrombolysis is superior to IV thrombolysis alone. In this case, the neurointerventional team should be mobilized and CT angiography ordered to assist in surgical planning, although protocols may vary. Hemicraniectomy is reasonable, but typically would be considered if edema appears on imaging studies obtained 12 to 24 hours later. Initiation of a heparin drip is contraindicated following thrombolysis and is of no expected benefit.
* Powers WJ, Derdeyn CP, Biller J, et al. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015 Oct;46(10):3020-3035.