A 65-year-old patient of CAD develops sudden onset right side face and arm weakness and expressive dysphasia. On admission BP= 160/100 mm Hg. NCCT was done. Which is the best step in the management of this patient?
**Core Concept**
The patient's symptoms of sudden onset right side face and arm weakness, expressive dysphasia, and elevated blood pressure in the context of a history of coronary artery disease (CAD) suggest a diagnosis of an ischemic stroke, likely involving the left middle cerebral artery (MCA) territory. The MCA is responsible for controlling motor and sensory functions of the face and arm on the opposite side of the body.
**Why the Correct Answer is Right**
The patient's symptoms are consistent with an MCA stroke, which is a medical emergency requiring prompt intervention. The management of acute ischemic stroke involves the use of intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) within 4.5 hours of symptom onset. The presence of elevated blood pressure in this patient does not contraindicate the use of rt-PA, as the benefits of timely reperfusion outweigh the risks of bleeding. In fact, the current guidelines recommend that blood pressure be managed to a systolic blood pressure of less than 185 mmHg and a diastolic blood pressure of less than 110 mmHg during thrombolysis.
**Why Each Wrong Option is Incorrect**
**Option A:** Administering aspirin without imaging would be inappropriate, as it does not address the underlying cause of the stroke and may delay diagnosis of other conditions such as hemorrhagic stroke.
**Option B:** Performing a CT angiogram would be a reasonable step, but it is not the best initial step in management, as it does not provide information on the presence of a large vessel occlusion, which is a critical determinant of the need for endovascular therapy.
**Option C:** Administering antihypertensive medications without imaging would be inappropriate, as it may worsen cerebral perfusion in the setting of an ischemic stroke.
**Clinical Pearl / High-Yield Fact**
In the setting of acute ischemic stroke, the use of intravenous thrombolysis with rt-PA is most effective when administered within 3 hours of symptom onset. However, even within the 3- to 4.5-hour window, timely reperfusion is critical to minimize long-term disability.
**Correct Answer:** C. Administer intravenous recombinant tissue plasminogen activator (rt-PA) after obtaining a non-contrast CT scan to rule out hemorrhage.