A patient is diagnosed with an ischemic stroke with the onset of symptoms within the last 2 hours. The best course of treatment for this patient would be to:

Question

1. Admit the patient to a neurosurgical unit for a surgery consultation.
2. Consider the administration of intravenous recombinant tissue-type plasminogen activator (rt-PA or alteplase).
3. Observe for continuing symptoms.
4. Provide intravenous fluids.

Answer 1

2
Rationale 1: If the CT scan is positive for a hemorrhagic stroke, an immediate neurosurgical consult should be ordered. Immediate surgery for an ischemic stroke is not indicated at this time. The priority is to re-establish blood flow to limit neurologic deficits and preserve neurologic function. Once the patient has been stabilized and has recovered, carotid endarterectomy may be considered if indicated.
Rationale 2: In the case of ischemic stroke, intravenous thrombolysis should be administered if the time since the onset of symptoms is less than 3 hours and the patient is eligible based on criteria.
Rationale 3: Merely observing the patient is not sufficient because as the obstruction continues, the neurologic deficits worsen. The priority is to re-establish blood flow as soon as possible.
Rationale 4: The use of IV fluids is a means to administer antihypertensive medications to control blood pressure. Fluid restriction may be indicated to assist in controlling hypertension but not so restricted to cause dehydration, which would increase blood viscosity, raising the risk of the development of more thromboemboli.