New Focal Deficit With a Normal Head CT

Step 1 - Time window. Last known well 2 hours ago, within the 4.5-hour intravenous thrombolysis window. Confirm with the wife that he was truly normal at that time; if onset is uncertain, use last known well.

Step 2 - Hemorrhage excluded. Noncontrast CT shows no hemorrhage. A normal CT at 2 hours does not exclude ischemia; early CT is often normal, and the decision to treat is clinical.

Step 3 - Anticoagulation status. He takes warfarin but INR is 1.4, which is below the 1.7 threshold that generally excludes thrombolysis. A documented INR ≤1.7 is acceptable per guidelines. This is the key judgment: do not reflexively exclude a warfarin patient - check the number.

Step 4 - Other contraindications. BP 178/96 is below the 185/110 threshold, so no pretreatment BP lowering is required (but monitor closely). Glucose normal. No recent surgery, GI bleed, or seizure described. NIHSS 7 is disabling and treatable.

Step 5 - Large vessel occlusion? NIHSS 7 with aphasia and face/arm weakness could reflect a dominant MCA occlusion. Obtain CTA/vascular imaging to assess for LVO, because he may be a candidate for mechanical thrombectomy even beyond the thrombolysis window.

Conclusion: He is a candidate for IV thrombolysis after confirming no other contraindications, and should be evaluated concurrently for thrombectomy.

Before thrombolysis: lower BP to <185/110 mmHg. His 178/96 is already below threshold, so proceed without pretreatment antihypertensives.

During and after thrombolysis: maintain <180/105 for at least 24 hours. Use labetalol or nicardipine with frequent monitoring; avoid abrupt drops that could worsen penumbral perfusion.

Anticoagulation and AF:

• Do not restart warfarin in the first 24 hours after thrombolysis; obtain follow-up imaging (typically 24 hours) before resuming any anticoagulant.
• His subtherapeutic INR and missed doses are the proximate cause of this stroke - this is a systems and adherence failure, not just a biology failure.
• After the acute period, address anticoagulation strategy: consider a direct oral anticoagulant (DOAC) for AF if renal function permits, which has better adherence and safety profiles than warfarin in many patients.
• Involve the patient and family in an adherence plan; missed-dose patterns must be identified and addressed.

Judgment being tested: knowing the INR and BP thresholds precisely, not treating a normal CT as evidence against stroke, and recognizing adherence failure as the root cause to prevent recurrence.

Fluctuation after thrombolysis suggests either:

1. Reocclusion or incomplete recanalization of the culprit vessel - particularly likely if he had an LVO that was not fully opened.
2. Hemorrhagic transformation - especially concerning after thrombolysis.
3. Cerebral edema with mass effect.
4. Seizure or post-ictal state masquerading as worsening.

Actions:

• Emergent noncontrast head CT to exclude hemorrhage before any further antithrombotic decision.
• Repeat vascular imaging (CTA) to assess vessel patency; if an LVO persists and he is within the thrombectomy window, he may still be a candidate.
• Neurologic reassessment with repeat NIHSS; check glucose, electrolytes, and oxygenation.
• Blood pressure and airway reassessment; if there is edema or deterioration, consider ICU-level care.
• Do not give additional thrombolytic - repeat dosing is not standard and increases hemorrhage risk.

Judgment being tested: recognizing that post-thrombolysis deterioration is a time-critical emergency with a defined differential, and that imaging comes before any further anticoagulation.