A 58-year-old man with hypertension and diabetes presents to the emergency department 2.5 hours after onset of acute left-sided weakness and slurred speech. On examination, he has a National Institutes of Health Stroke Scale (NIHSS) score of 8. CT head (non-contrast) shows no hyperdensity or hypodensity. Blood glucose is 180 mg/dL. What is the most appropriate immediate next step in management?

Explanation

## Clinical Context This patient presents within the 4.5-hour thrombolytic window (2.5 hours from onset) with acute ischemic stroke symptoms and a non-contrast CT showing no hemorrhage. The NIHSS score of 8 indicates moderate neurological deficit. ## Key Point: **Intravenous thrombolysis (rt-PA) is the standard of care for acute ischemic stroke within 4.5 hours of symptom onset, provided hemorrhage is excluded and no absolute contraindications exist.** [cite:Harrison 21e Ch 446] ## Management Algorithm ```mermaid flowchart TD A[Acute ischemic stroke suspected]:::outcome --> B{Time since onset?}:::decision B -->|< 4.5 hours| C[Non-contrast CT to exclude hemorrhage]:::action C --> D{Hemorrhage present?}:::decision D -->|No| E[Check coagulation profile & glucose]:::action E --> F{Contraindications to thrombolysis?}:::decision F -->|No| G[Administer IV rt-PA 0.9 mg/kg]:::action F -->|Yes| H[Consider mechanical thrombectomy]:::action D -->|Yes| I[Neurosurgery consult]:::urgent G --> J[Reperfusion & neurological recovery]:::outcome B -->|> 4.5 hours| K[Assess for thrombectomy window]:::decision ``` ## Rationale for Correct Answer **High-Yield:** The patient meets all inclusion criteria for IV thrombolysis: - Symptom onset < 4.5 hours (2.5 hours) - Non-contrast CT excludes hemorrhage - No mention of contraindications (recent surgery, anticoagulation, INR > 1.7, platelet count < 100,000) - Moderate deficit (NIHSS 8) with potential for functional improvement **Clinical Pearl:** Hyperglycemia (180 mg/dL) is NOT a contraindication to thrombolysis — it is a common finding in acute stroke and does not preclude treatment. However, extreme hyperglycemia (> 400 mg/dL) or hypoglycemia should be corrected first. **Key Point:** Coagulation profile (PT/INR, aPTT) should be checked before administration but should NOT delay thrombolysis if clinical suspicion is high and no bleeding history exists. The window is narrow and every minute of delay increases irreversible brain damage. ## Standard rt-PA Dosing - **Total dose:** 0.9 mg/kg (maximum 90 mg) - **Bolus:** 10% of total dose IV over 1 minute - **Infusion:** Remaining 90% over 60 minutes ## Absolute Contraindications to IV rt-PA - Active bleeding or hemorrhagic stroke on imaging - Recent intracranial surgery, head trauma, or stroke (< 3 months) - INR > 1.7 or aPTT prolonged - Platelet count < 100,000/μL - Blood glucose < 50 mg/dL or > 400 mg/dL (relative) - Seizure at stroke onset (relative) **Warning:** Do NOT delay thrombolysis waiting for all investigations if clinical presentation is clear and CT excludes hemorrhage.