8/8/23 L MCA Stroke

A middle cerebral artery MCA stroke occurs when blood flow from the MCA, one of the largest arteries of the brain, is suddenly impeded. The loss of blood flow causes tissue death, leading to brain injury.

You are paged to CT scanner 2.

Patient 72 y/o male with history of hypertension, atrial fibrillation, and prior tobacco use presents for evaluation of L sided weakness. He reports that his symptoms began approximately 2 hours priors to evaluation. He states that his left arm and leg both feel weak. He is bit anxious and concerned about weakness.

His vital signs are below:

HR: 90

BP: 220/110

RR: 19

O2 sat: 98% RA

T: 37 C

Initial assessment begins at the CT scanner. His initial blood pressure is elevated. The plan is to complete the initial exam including NIH Stroke Scale. The patient appears to be a TNK candidate, however is blood pressure is quite high.

Examination

Pupils equal, round and reactive to light and accommodation. Lungs are clear to auscultation bilaterally. His abdomen is non tender non distended. On extremity assessment: 5/5 muscle strength in right upper extremity and right lower extremity. 4/5 muscle strength in the left upper extremity and left lower extremity. Patient is alert and oriented to person, place and time. The patient has no ataxia.

What would your next steps be?

• Obtain brief history

• Activate Stroke page

• Glucose

• Preform NIHSS

• Obtain CT head

• Recognize elevated BP.

Initial Evaluation:

VS: BP 200/100 HR 90 RR 14 98 % RA 98.6

According to the medical records Glucose 90, INR 1.0. CT head, no evidence of acute Intra-Cranial Hemorrhage. Physical examination without changes.

What are our next steps?

• Obtain Last Know Well

• Assess inclusion criteria for thrombolytic therapy

• Obtain medical history for possible contraindications for thrombolytic therapy

• Medications to decrease blood pressure

• When considering tenecteplase (TNK):

The patient receives labetolol for hypertension, his repeat vitals:

BP160/73 HR 80 RR 14 98 % RA 98.6 *F

Unchanged in physical exam/condition, has a normal PT/PTT, and his platelets are 250.

Normal head CT scan below.

This patient receives tenecteplase.

References:

1. Case courtesy of David Cuete, Radiopaedia.org, rID: 23768

Normal CT brain | Radiology Case | Radiopaedia.org

normal head CT

2.TNK picture Boehringer Ingelheim - Value Through Innovation | Boehringer Ingelheim (boehringer-ingelheim.com)