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A 62-year-old male with a history of hypertension and diabetes presents to the emergency department with a left facial droop and left-sided hemiparesis. He is not sure when the symptoms began. His wife noted that 4 h before he arrived at the hospital he was "normal" but did not see him again until 20 min before presentation. Past medical history is significant for reflux esophagitis seen on endoscopy 1 year ago. His medications include hydrochlorothiazide and omeprazole. Family history is noncontributory. Physical examination is notable for a blood pressure of 152/74 mmHg and an oxygen saturation of 98% on room air. He has an obvious left facial droop and has left-sided hemiparesis. Sensation is intact. The patient's stool is heme-negative. A complete blood count is normal, and coagulation studies are within normal limits. A computed tomography scan of the head shows a right middle cerebral artery territory infarct. There is no hemorrhage. What is the most appropriate next management step?
A. Aspirin B. Clopidogrel C. Intraarterial catheter-based thrombolytic therapy D. Intravenous thrombolytic therapy E. Intravenous heparin
cyra Moderator
Topics: 29 Posts: 844
07/02/06 - 02:57 PM
#2
A.Aspirin
Thrombolytic therapy won't be given cos the presentation is not within three hours of onset and the onset isn't exactly documented.Not heparin because I don't think there is a high risk of recurrent CVA here.Aspirin is supposed to be tried before clopidogrel...if that fails then clopidogrel is given.I hope I am on the right track here.
MAZI Forum Elite
Topics: 8 Posts: 245
07/02/06 - 11:11 PM
#3
I THINK D
frontal Forum Guru
Topics: 53 Posts: 421
07/03/06 - 01:10 AM
#4
D. He was normal 4 hours ago, so I think i.v. thrombolysis would be indicated.
achilles Forum Guru
Topics: 90 Posts: 1,228
07/03/06 - 04:24 AM
#5
D ? (but agree with cyra that it may be more than 3 hrs since onset).
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frontal Forum Guru
Topics: 53 Posts: 421
07/03/06 - 06:05 AM
#6
Some sources mention 6 hours as the cut-off. This case is well within 4.
drk1980 Forum Guru
Topics: 147 Posts: 1,038
07/03/06 - 08:56 AM
#7
Agree with Aspirin.
Views hv been oscillating between 90minutes and 3hours for tPA use...isnt 6 hours a bit much?
Isther Forum Guru
Topics: 39 Posts: 744
07/03/06 - 09:09 AM
#8
I agree with D.
But, I remember a few trials about Intraarterial catheter-based thrombolytic therapy 3 years ago just don't know if it is a standard therapeutic option now.
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ARJ Forum Guru
Topics: 133 Posts: 792
07/03/06 - 09:23 AM
#9
Aspirin ___________________ "Live as if you were to die tomorrow. Learn as if you were to live forever." --Mahatma Gandhi
luabe Forum Junior
Topics: 11 Posts: 23
07/03/06 - 12:21 PM
#10
aspirin is first line in secondary prevention of ischemic stroke TPA are contraindicated after 3 hours accord to Kaplan
nida Forum Elite
Topics: 23 Posts: 87
07/03/06 - 01:47 PM
#11
The answer is C.
Acute ischemic stroke results from an acute occlusion of an intracranial vessel from in situ thrombosis or an embolic source. The magnitude of the flow reduction is a function of the collateral blood flow, and this depends largely on the vascular anatomy of the individual patient. Brain tissue dies within minutes of a fall in cerebral blood flow. Therefore, reestablishment of flow and prevention of widening of the territory of infarction are two of the major goals of stroke therapy. A pivotal National Institute of Neurological Disorders and Stroke (NINDS) study showed that patients who received intravenous recombinant tissue plasminogen activator (rTPA) within 3 h of the onset of symptoms had a significant clinical benefit. This was the case despite a 6.4% risk of intracerebral hemorrhage. Other, more recent trials have looked at intraarterial delivery of rTPA by a catheter-based approach within a 6-h time frame for middle cerebral artery (MCA) territory infarctions, and there appears to be a significant benefit. Although this has not been approved by the U.S. Food and Drug Administration, based on early clinical trials, it is rapidly becoming the standard of care for patients with MCA strokes that fall out of the 3-h window for intravenous rTPA. Numerous studies have shown the benefit of aspirin administered within 48 h of stroke onset. Aspirin offers a modest benefit in regard to further stroke recurrence. Some literature supports a benefit of clopidogrel in ischemic stroke patients as a means of secondary prevention. Although frequently used, heparin remains unproven as a beneficial agent in the treatment of acute stroke. Because this patient has no contraindication to thrombolytic therapy but falls outside the 3-h window for intravenous rTPA, catheter-delivered rTPA is the next best option if the support facilities exist and should be recommended for this patient.
(Q from Harrison Self-Assessment test)
drk1980 Forum Guru
Topics: 147 Posts: 1,038
07/03/06 - 01:50 PM
#12
nice Qs nida...
Isther Forum Guru
Topics: 39 Posts: 744
07/03/06 - 02:21 PM
#13
Awsome!!! nice question!!!
One thing, what do you think I should answere in case I face this question in the exam? Because Kaplan still says intravenous.
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Isther Forum Guru
Topics: 39 Posts: 744
07/03/06 - 02:24 PM
#14
Talking of which... there are several new guidelines recently published and updated, what shoud I answer in a case like this in which must decide between a new vs. an old concept?? ___________________ Useful information for USMLE and the residency matching process at http://www.usmlematch.com
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