CME

Patient Management
Address correspondence to
Dr Adam Kelly, University of
Rochester, 601 Elmwood
Avenue, PO Box 673,
Rochester, NY 14642-0001,
Adam_kelly@urmc.rochester.edu.
Relationship Disclosure:
Problem
Dr Kelly has received research Adam G. Kelly, MD
support from the Donald W.
Reynolds Foundation and
compensation from the
American Academy of
Neurology as a question writer The following Patient Management Problem was chosen to reinforce the
for Continuum.
subject matter presented in the issue. It emphasizes decisions facing the
Unlabeled Use of
Products/Investigational practicing physician. As you read through the case you will be asked to
Use Disclosure: complete 12 questions regarding history, examination, diagnostic evalua-
Dr Kelly reports no disclosure.
* 2014, American Academy
tion, therapy, and management. For each item, select the single best
of Neurology. response.
In order to obtain CME credits, subscribers must complete this Patient
Management Problem online at www.aan.com/continuum/cme. A tally
sheet is provided with this issue to allow the option of marking answers
before entering them online. A faxable scorecard is available only upon
request to subscribers who do not have computer access or to
nonsubscribers who have purchased single back issues (send an email
to ContinuumCME@aan.com).
Upon completion of the Patient Management Problem, participants may
earn up to 2 hours of AMA PRA Category 1 Creditsi. Participants have up
to 3 years from the date of publication to earn CME credits. No CME will
be awarded for this issue after April 30, 2017.

Learning Objectives
Upon completion of this activity, the participant will be able to:
& Describe the early management of patients with acute ischemic stroke,
including the use of IV thrombolytic therapy
& Select appropriate diagnostic tests to be used in the initial evaluation of
patients with ischemic stroke
& Discuss evidence-based strategies for secondary stroke prevention after
stroke or transient ischemic attack

Case
A 64-year-old man is brought to the emergency department by ambulance
after developing the acute onset of left-sided weakness and left-sided
neglect. Because of his neglect, he has difficulty acknowledging his
symptoms and is unable to state the exact time of their onset. He reports
that his medical history is notable for hypertension and hyperlipidemia and
states that he is not currently taking any medications. He reports no recent
hospitalizations, bleeding events, or other relevant history.
Continued on page 477

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 Continued from page 476
On initial evaluation, his blood pressure (BP) is 177/80 mm Hg, pulse is
80 beats/min and regular, and he is afebrile. He is awake but inattentive.
Language is intact but speech is mildly dysarthric as a result of weakness of
the left lower face. Eye movements and visual fields are full, but he has
extinction to double simultaneous visual stimulation on his left side. He is
able to briefly lift his left arm and leg, but both drift down to the bed
within seconds. He notes decreased sensation on his left side compared to
the right and has extinction to double simultaneous tactile stimulation on
the left side. The NIH Stroke Scale (NIHSS) score is 10.
Head CT is completed and shows no signs of intracranial hemorrhage or
early ischemic changes. Finger-stick blood glucose is 103 mg/dL.

b 1. Which of the following clinical or diagnostic features is most critical to

determine whether IV thrombolytic therapy may be indicated in this patient?
A. assessing results of coagulation studies (eg, plasma thromboplastin, partial
thromboplastin time)
B. evaluating response of BP to labetalol 10 mg intravenously
C. identifying a clear time of symptom onset
D. inquiring about a possible prior history of ischemic stroke
E. obtaining a CT angiogram of the brain to evaluate for intracranial vascular
occlusion

The patient’s family arrives in the emergency department and reports that
he was in his usual good neurologic health until 90 minutes ago, at which
point he had the witnessed onset of the left-sided weakness and other
symptoms now seen on examination. His family confirms that he has
had no recent prior stroke symptoms, head trauma, bleeding events,
seizure activity at the start of his symptoms, nor history of intracranial
hemorrhage. His examination has not significantly changed since arrival
at the hospital, and his BP is now 169/84 mm Hg.

b 2. Which of the following therapeutic or diagnostic options is the best next

step in management of this patient?
A. administration of alteplase
B. administration of aspirin 325 mg and clopidogrel 75 mg
C. monitoring for 30 to 60 minutes to allow for possible symptom improvement
D. MRI of the brain with diffusion-weighted imaging
E. referral for mechanical thrombectomy

The risks and benefits of tissue plasminogen activator (tPA) treatment are
discussed with the patient and his family, and they agree to treatment;
the tPA bolus is administered at 2 hours and 15 minutes after symptom
onset. At the end of the tPA infusion, his examination has shown some
improvement. His neglect is significantly better, and the left-sided weakness,
while still present, is also improved. The NIHSS score is now 4. He is transferred
to the intensive care unit (ICU) for close neurologic monitoring.

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 Patient Management Problem

b 3. Which of the following is part of the recommended management of this

patient after treatment with IV tPA?
A. immediate administration of aspirin 81 mg
B. placement of a Foley catheter
C. referral for mechanical thrombectomy
D. repeat brain imaging at 24 hours after treatment
E. subcutaneous heparin for venous thromboembolism prophylaxis

The patient spends 24 hours in the ICU with some continued improvement
in his symptoms. An MRI scan performed 1 day after treatment shows
a wedge-shaped area of acute infarction affecting the right frontal
lobe and no signs of intracranial hemorrhage. His examination is now notable
only for the left facial droop and dysarthria; the NIHSS score is 2. His
systolic BP has ranged between 150 mm Hg and 170 mm Hg since he was
admitted to the hospital.

b 4. Which of the following is the best next step in management?

A. begin aspirin 325 mg/d
B. begin IV unfractionated heparin infusion
C. continue ICU monitoring for another 24 hours
D. lower BP to less than 140/90 mm Hg
E. refer for cerebral angiogram

The patient is transferred to the stroke unit for continued care. The
following diagnostic test results are obtained.
& Magnetic resonance (MR) angiogram of the neck: no evidence of
carotid or vertebral artery stenosis
& MR angiogram of the head: no intracranial stenosis or occlusion
& Transthoracic echocardiogram: left ventricle ejection fraction 55%;
no regional wall motion abnormalities; no sign of intracardiac
thrombus; no significant valvular disease
& 48 hours of continuous ECG monitoring: normal sinus rhythm, no
significant dysrhythmia
& Fasting lipids: Total cholesterol 210 mg/dL; triglycerides 223 mg/dL;
high-density lipoprotein (HDL) 34 mg/dL; low-density lipoprotein
(LDL) 136 mg/dL

b 5. Which of the following diagnostic tests is the best next step in management?
A. carotid ultrasound
B. genetic testing for factor V Leiden
C. MR venogram of the pelvis
D. transcranial Doppler ultrasound
E. transesophageal echocardiogram

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b 6. Which of the following is the best option for management regarding his
fasting lipids?
A. adherence to a low-fat diet
B. atorvastatin
C. ezetimibe
D. fenofibrate
E. niacin

His transesophageal echocardiogram is unremarkable for any source of

cardioembolism. He is discharged from the hospital on aspirin 325 mg/d
and atorvastatin 40 mg/d.
The patient is seen in the neurology clinic 3 weeks after his stroke. He has
continued to make additional progress on his recovery; he now notes only some
minimal trouble articulating his speech, usually when he is tired or fatigued. He
reports no new symptoms concerning for recurrent stroke or TIA and is
tolerating his aspirin without any adverse effects. His BP today is 155/90 mm Hg.
While he does not check his BP regularly outside of a physician’s office, he says
the reading was similar when he saw his primary care physician 1 week ago.

b 7. Which of the following is the best approach to BP management in this patient?

A. begin low-salt diet alone
B. continue to allow for permissive hypertension for 1 to 2 months poststroke
C. order renal ultrasound to assess for renal artery stenosis
D. prescribe hydrochlorothiazide 12.5 mg/d
E. recheck BP in 1 week

b 8. Which of the following is the best long-term BP goal in this patient?

A. diastolic BP lower than 80 mm Hg
B. mean arterial pressure lower than 100 mm Hg
C. systolic BP between 120 mm Hg and 140 mm Hg
D. systolic BP lower than 120 mm Hg
E. systolic BP lower than 150 mm Hg

Three months later, he returns to clinic with concerns about ongoing

fatigue. He notes that this was a problem before his stroke but that it has
been considerably worse over the past few months. Despite getting an
average of 8 hours of sleep per night, he does not feel particularly
refreshed when he awakens in the morning, and he notes a tendency to
doze while he is sitting at his desk attempting to work. His BP has
continued to be elevated despite an increase in his hydrochlorothiazide
and the addition of a low dose of lisinopril; his BP is 141/93 mm Hg in clinic
today. Examination is unchanged from his prior visits.

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 Patient Management Problem

b 9. Which of the following is the most likely cause of his fatigue?

A. adverse effects of hydrochlorothiazide
B. hypothyroidism
C. obstructive sleep apnea
D. poststroke depression
E. recurrent stroke affecting the left caudate nucleus

He is referred to a local sleep center, where he receives an overnight

polysomnogram and is found to have moderate to severe obstructive sleep
apnea, with an apnea-hypopnea index of 31 events per hour. He is
started on continuous positive airway pressure (CPAP). He phones the
office 1 month after initiation of treatment and notes that his fatigue is
considerably improved. He has also been checking his BP on a consistent
basis at home and reports that his typical readings have been between
130 mm Hg and 135 mm Hg systolic and 80 mm Hg and 85 mm Hg diastolic.
One year later, the patient is admitted to the hospital after awakening
with the onset of right upper extremity weakness and expressive aphasia.
An MRI shows a small area of infarction in the left frontal lobe. Vascular
imaging shows no evidence of carotid or intracranial stenosis. His
admission electrocardiogram shows an irregularly irregular rhythm con-
sistent with atrial fibrillation, and he reports several episodes of palpita-
tions over the past several weeks.

b 10. Which of the following is the best next step in management?

A. add clopidogrel to aspirin
B. change to combination aspirin/extended-release dipyridamole
C. change to dabigatran
D. refer for cardioversion; if successful, stop antithrombotic therapy
E. refer for left atrial appendage occlusion

After 4 days on the stroke unit for additional testing and monitoring, he
is discharged to acute rehabilitation for ongoing management of his
right-sided weakness and functional limitations. Before discharge, the
various options for stroke prevention in the setting of atrial fibrillation
are discussed with the patient, and dabigatran (150 mg twice daily)
is prescribed.

b 11. Early administration of which of the following medications, in addition to

physiotherapy, has been associated with improved motor recovery following stroke?
A. amantadine
B. baclofen
C. donepezil
D. fluoxetine
E. memantine

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 Six weeks after discharge from the acute rehabilitation unit, he is seen in
clinic and his right-sided strength has improved considerably. He still has
difficulty with activities that require significant dexterity of the right hand,
such as buttoning his shirt, but has returned to nearly all of his previous
activities. His expressive aphasia has completely resolved, and he denies
any residual language dysfunction. He is tolerating his dabigatran without
any bruising, bleeding, or other side effects.
His family asks about dietary recommendations for stroke prevention,
specifically inquiring about the evidence for a Mediterranean-type diet.

b 12. Which of the following best explains the current evidence for an
association between adherence to a Mediterranean diet and stroke risk?
A. even low-to-moderate diet adherence is associated with a lower risk of stroke
B. high diet adherence is associated with a lower risk of dementia but not stroke
C. high diet adherence is associated with a lower risk of stroke
D. high diet adherence is associated with an increased risk of stroke
E. high diet adherence is not associated with a lower risk of stroke

Six months later, the patient is seen in clinic. He has remained free of any
new symptoms suggestive of cerebral ischemia and continues to tolerate
his anticoagulation without adverse effects. His daytime fatigue is
considerably better with compliance with CPAP therapy. Blood pressure in
the clinic is 127/80 mm Hg, and recent lipids drawn by his primary care
provider show his LDL to be 78 mg/dL.

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