A 32-year-old man with no past medical history is brought in for slurred speech and left-sided weakness.  He was having intercourse when he had acute onset headache, slurred speech, and slumped over with weakness of left arm and left leg.  In the field, HR 88 BP 170/80 RR 20 100% O2, blood glucose 72.
On arrival, this patient is not alert but arousable to voice, looking to the right with left-sided neglect, pupils reactive 4 mm to 3 mm OU, left upper extremity 2/5 motor response to painful stimulus, left lower extremity 3/5 motor response to same. There is no sensation to the left upper extremity.  He has no evidence of trauma, no murmur, and is in normal sinus rhythm on the monitor.
CT non-contrast is performed immediately:
On arrival from the radiology suite, the man has complete resolution of signs and symptoms and has a completely normal repeat neurologic exam.
Regarding his presentation and management, which is the BEST answer:
    A. Obtain emergent neurosurgery consultation for possible coil embolization
    B. Initiate titratable anti-hypertensive agent to target systolic blood pressure 
         of 140 mmHg
    C. Give alteplase 0.9 mg/kg actual body weight o a maximum of 90 mg/kg
    D. Give aspirin 325 mg PO

In the meantime, a quote --  

"You medical people will have more lives to answer for in the other world than even we generals."  

-- Napoleon Bonaparte


11/19/2012 11:52am

Image displays right hyperdense MCA sign likely representing thrombus. With complete resolution of symptoms, I suspect recanalization of the artery. Answer D.


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