A 73-year-old woman, with prior parietal intraparenchymal hemorrhage approximately 6 months prior and ischemic stroke approximately 2 years prior, presents to the emergency department after being found slumped in a chair at home and unresponsive. She was intubated for airway protection, and a head CT demonstrated a large left frontal intracerebral hemorrhage with intraventricular extension and SAH as well as 5 mm of left-to-right midline shift. Her pertinent medications at home are metoprolol 25 mg daily and aspirin 81 mg daily. Her vital signs in the emergency department are heart rate (HR) 86, blood pressure (BP) 124/68, and SpO2 98% on 40% FiO2 . Her basic metabolic panel and complete blood count are normal. Her only medication at the time of evaluation is propofol for sedation.
What medications/treatments should be added to the patient’s current regimen?
Correct Answer: E
There are no additional medications that are needed at this time. Given her intracerebral hemorrhage, she should have aggressive BP management to maintain a systolic BP goal of <140 for at least the first 24 hours. The patient’s BP is currently below the goal target of 140 mm Hg, so no additional intervention is needed. Intracerebral hemorrhage can result in early clinical seizure, but these early seizures do not change clinical outcomes and the use of prophylactic antiepileptics is not recommended as they might worsen patient’s outcome. Lastly, the use of antiplatelet agents before an intracerebral hemorrhage can be a confounding factor. Based on the results of the PATCH study, platelet transfusions are not recommended for use in the setting of intracerebral hemorrhage while taking antiplatelet medication as they appear to increase risk of death or dependence.
A 64-year-old man with hypertension is brought to the emergency department for acute-onset (within the last 60 minutes) left face, arm, and leg weakness. A noncontrast head CT is completed and does not demonstrate a hemorrhage or early ischemic changes. His vitals are BP 174/120, HR 76, and SpO2 99% on room air. A fingerstick blood glucose was obtained and was 127, but other labs are pending.
What is the next BEST step in management for the patient?
Ischemic stroke is a common neurologic emergency that can result in permanent disability and death. Intravenous tPA has been studied in multiple trials and been found to be effective in acute stroke treatment. The American Heart Association, American Academy of Neurology, and the American Stroke Association have recommendations on the use of tPA in the treatment of ischemic stroke. There are exclusion criteria for treatment with tPA. The initial American tPA study was the NINDS trial, which demonstrated safety (same mortality at 90 days) and efficacy (improved neurologic outcome at 90 days) with use of tPA within 3 hours of neurologic symptoms. ECASS-II and ECASS-III extended the time window from last known well to 4.5 hours. These data demonstrate improved neurologic outcome with treatment in the 3 to 4.5 hour window but further extended to 6 hours with no difference in mortality or outcome. The feared complication of intracerebral hemorrhage can occur with IV tPA treatment. In the case above, the patient has an absolute contraindication to tPA administration, which is BP >185/>110. Treatment of the BP to below this level can then allow for tPA administration, so option E is the right choice.
A 69-year-old female with hypertension presents to the emergency department from home following acute onset of slurred speech and left facial droop. She was with her family watching television when her daughter noted the symptoms. Emergency medical services (EMS) was called and noted left facial droop, left arm weakness, and dysarthria. Her initial vitals were unremarkable other than a BP of 212/92. She was treated with IV labetolol with BP improvement and was treated with IV tPA. Thirty minutes into the infusion she complained of a headache and became less responsive. Her BP was 190/86, and the tPA was stopped. A repeat head CT was completed and is shown in the figure that follows:
Axial noncontrast head CT. There is a large right MCAacute ischemic stroke with edema and effacement of the sulci. There is hemorrhage present within the area of ischemia centered in the right basal ganglia and insula.
Other than BP management, what is the next best step in management of her current neurologic issue?
Correct Answer: D
For every 100 patients treated with tPA, 1 patient will experience a severely disabled or fatal outcome as a result of tPA-related hemorrhage. The treatment of symptomatic hemorrhage following tPA administration has not been studied in a randomized fashion. In patients with hypofibrinoemia (level <150 mg/dL) post tPA, cryoprecipitate is recommended to increase this level as those with low fibrinogen had hematoma expansion and worse outcomes. Although fresh frozen plasma contains the same clotting factors as cryoprecipitate, they are not as concentrated and would require a larger volume and would not correct the low fibrinogen level as quickly. TXA and aminocaproic acid can be used for uncontrolled and life-threatening hemorrhage following tPA administration, but these should not be considered first-line therapy, given the complications of prothrombic state that can occur. The dose noted for TXA listed above was studied in trauma patients and demonstrated decreased risk of death. Lastly, use of prothrombin complex concentrate and vitamin K can be used for vitamin K antagonist hemorrhage but play little role in treatment of tPA hemorrhage.
A 54-year-old man with no past medical history was brought into the emergency department by his wife for altered mental status. On arrival to the emergency department, the only pertinent history and findings were an ongoing holocephalic headache and some confusion. A noncontrast head CT demonstrated a right frontoparietal intraparenchymal hemorrhage. The patient was stabilized and taken for a diagnostic angiogram, which is shown in the figure below. The figure is a right internal carotid injection projected as an anterior-posterior view. He was diagnosed with an arteriovenous malformation (AVM).
Which of the following statements is true regarding this patient and his AVM?
Correct Answer: C
AVMs are abnormal, direct connections between arteries and veins without intervening capillary beds and no normal brain tissue among the blood vessels. AVMs are typically congenital but can grow with time. Typical presenting symptoms of AVMs are seizures and intraparenchymal hemorrhage as these may not be isolated to the brain. The risks of AVM surgical mortality and morbidity are characterized based on the AVM size, location, and type of venous drainage. With increased use of intracranial imaging, asymptomatic AVMs are increasingly documented, which should be closely followed.
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