Aashi
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A 66-year-old man with hypertension and diabetes presents to the emergency department two hours after developing acute weakness of the left side of his body. He fell from a chair at home while watching TV. He lost consciousness and was noted by his wife to have left arm and leg twitching, which resolved spontaneously at home. His current medications are aspirin, metoprolol, and metformin, with which he is compliant. On examination, he is alert and awake with a blood pressure of 190/100 mm Hg. He has dysarthric speech and left-sided face, arm, and leg weakness. There is no evidence of seizure activity in the emergency department. A head CT scan is done in the emergency department (about 2.5 hours after the onset of symptoms) that showed bilateral cortical atrophy and a lacunar infarction of the left putamen. There is no hemorrhage. What is the most appropriate therapeutic option at this stage?
(A) Control blood pressure, then give tPA
(B) Control blood pressure and add clopidogrel
(C) Start intravenous heparin
(D) Load with phenytoin and add clopidogrel
(E) Give tPA immediately
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| CocaCola
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E - give tPA immediately...
we only have a three hour window
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| prathapdoctor
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blood pressure must not be decreased immediately in a patient with stroke unless it is more than 190/110,so in this patient we can go for tPA immediately without decreasing blood pressure.
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| sarika
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but a systolic BP of more than 185 or diastolic more than 110 is a contraindication to tpa therapy...control bp and give clopidogrel
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| robin082006
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This is embolic stroke, E is the best choice.
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| MDcooper
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I agree with sarika.anticoagulants are CI here.Plus he is susceptible to another seizure.we must lower the BP first and give clopidogrel
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| doc_clotaire
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From my point of view , the patient does not fit the criteria for NOT GIVING tPA because his systolic BP may be higher than 180 but his diastolic is still less than 110 mm Hg . I don ' t know how strict they could be about that but I would go for E
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| Aashi
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This was a tricky q..Unfortunately no1 answered it correctly..
The Correct ANS is --->(D) Load with phenytoin and add clopidogrel
This patient has two contraindications to thrombolytic therapy with tPA, which are severe hypertension and seizures at the onset of the stroke. While the hypertension may be controlled, the fact that this patient had a seizure should make one think of a possibility of a Todd's paralysis, in which case the patient should not be given tPA. Todd's paralysis is a transient, focal, neurological deficit occurring just from a seizure and resolving spontaneously. We need to control the seizures in this patient with phenytoin. Clopidogrel is added because of the possibility of having a stroke while on aspirin.
Heparin is rarely used for a stroke. Most patients do not receive heparin unless there is atrial fibrillation, a stroke in evolution with progressively worsening neurological deficits, or basilar artery thrombosis. It is not routinely used for patients in sinus rhythm with large neurological deficits because it can lead to an increased risk of intracranial hemorrhage. Thrombolytic therapy is indicated for an acute ischemic stroke when a patient presents within three hours of the onset of the neurological deficit. You must first obtain a baseline CT scan of the head to exclude an intracranial hemorrhage.
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| sarika
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hey ashi thanks for the question and explanation..can you tell me the source of these questions?
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| Aashi
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These are Fisher Qs and also some of them are from NMS..
GL
Edited by Aashi on 01/10/07 - 07:33 PM
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