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Difficulty: MediumDiagnostic Workup and Test Sequencing

A 58-year-old male is brought to the emergency department by his spouse due to sudden-onset neurological deficits. Approximately 45 minutes prior to arrival, he abruptly developed difficulty speaking and right-sided weakness while eating dinner. His medical history is significant for essential hypertension and hyperlipidemia, for which he takes amlodipine and atorvastatin. He has no history of bleeding disorders and does not take any anticoagulant medications. Vital signs show a blood pressure of 175/95 mmHg, heart rate of 82/min, and respiratory rate of 16/min. Neurologic examination reveals expressive aphasia, a right-sided facial droop, and 2/5 muscle strength in the right upper and lower extremities. The clinical team is evaluating the patient for acute reperfusion therapy with intravenous alteplase. Which of the following diagnostic studies MUST be obtained and their results reviewed prior to the administration of this therapy? (Select all that apply)

  1. Point-of-care blood glucose measurementAnswer
  2. Non-contrast computed tomography of the headAnswer
  3. C
    Complete coagulation profile (PT, INR, and aPTT)
  4. D
    Magnetic resonance imaging of the brain without contrast
  5. E
    12-lead electrocardiogram

Answer

The correct diagnostic studies that must be obtained and reviewed prior to thrombolytic therapy are point-of-care blood glucose measurement and non-contrast computed tomography of the head.
For a patient presenting with an acute ischemic stroke, the American Heart Association/American Stroke Association (AHA/ASA) guidelines dictate that time is brain. The only test results absolutely required before initiating intravenous alteplase (tPA) in a typical patient are a non-contrast head CT (to definitively rule out intracranial hemorrhage) and a blood glucose assessment (to rule out hypoglycemia, which can present as a stroke mimic). Delaying reperfusion for any other testing reduces the likelihood of a favorable neurological outcome.

Step-by-Step Solution

1
Identify the patient's clinical presentation and the proposed intervention.
The patient is presenting with signs of an acute ischemic stroke within the 4.5-hour therapeutic window for intravenous alteplase (tPA).
Establishing the timeline and likely diagnosis dictates the urgency and specific pathway of the diagnostic workup.
2
Determine the absolute requirements prior to administering intravenous thrombolytics.
The guidelines mandate ruling out two critical conditions: hypoglycemia (which can mimic a stroke) and intracranial hemorrhage (which is an absolute contraindication to tPA).
Administering tPA to a patient with a hemorrhage is often fatal, and giving it to a patient with isolated hypoglycemia exposes them to unnecessary bleeding risks without any benefit.
3
Select the appropriate tests to rule out these contraindications without delaying care.
A point-of-care blood glucose measurement is selected to rule out hypoglycemia, and a rapid non-contrast head CT is selected to exclude hemorrhage.
Both tests are highly sensitive for their respective rule-outs and can be performed quickly, minimizing door-to-needle time.

Key Concept

In patients presenting with suspected acute ischemic stroke who are candidates for thrombolytic therapy, the only diagnostic tests that must invariably be performed and reviewed prior to the administration of intravenous alteplase are a non-contrast head CT (or MRI) and a blood glucose measurement.
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Diagnostic Workup and Test Sequencing

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