Advanced🧠 Neurological 45 min scenario

Acute Ischemic Stroke

A 76-year-old female is brought in with sudden right-sided weakness and slurred speech. Apply the stroke chain of survival and tPA eligibility criteria.

Patient Presentation

Age: 76 years

Sex: Female

Weight: 68 kg

Allergies: NKDA

History: Atrial fibrillation (on apixaban), hypertension, hyperlipidemia, hypothyroidism

Chief Complaint: Right-sided weakness and slurred speech — onset 1 hour ago

Medications: Apixaban 5mg BID, Amlodipine 10mg, Atorvastatin 40mg, Levothyroxine 75mcg

Mrs. L was having breakfast with her husband when she suddenly dropped her fork and slurred her words. Her husband called 911 immediately. EMS arrived within 10 minutes. Last known normal (LKN) time: 0745 — 1 hour and 15 minutes ago. On arrival: BP 185/105, HR 88 (AFib), RR 16, SpO2 97%, Temp 98.6°F. She has right-sided facial droop, right arm weakness (cannot raise), slurred speech, and appears frustrated.

Assessment Findings

Vital signs: BP 185/105, HR 88 (AFib), RR 16, SpO2 97%, Temp 37.0°C
Neuro: NIHSS score 12 (moderate stroke)
Right facial droop, right arm pronator drift, right leg weakness
Slurred speech (dysarthria), mild expressive aphasia
No visual field deficit, no sensory neglect
GCS: 14 (oriented × 3, follows commands)
CT head (non-contrast): no hemorrhage, no early ischemic changes
CT angiogram: occlusion of left middle cerebral artery (MCA)
Blood glucose: 110 mg/dL (rule out hypoglycemia as stroke mimic)
INR: 1.1 (apixaban effect — cannot give tPA while on anticoagulant)

Nursing Priorities

1
Confirm stroke onset time — last known normal (LKN) determines treatment eligibility
2
STAT non-contrast CT head — rule out hemorrhage
3
Assess tPA eligibility — patient is on apixaban (contraindication)
4
Blood pressure management — lower to allow mechanical thrombectomy
5
Rapid activation of stroke team and neurointerventional team
6
Assess NIHSS — determines severity and treatment options

Nursing Interventions

Establish exact last known normal (LKN) time: 0745 — within 4.5h window for tPA, within 6h window for thrombectomy
Obtain non-contrast CT head STAT — done, no hemorrhage → ischemic stroke confirmed
Check blood glucose immediately — hypoglycemia (BG <60) can mimic stroke. Normal: 110 → not a mimic
Review tPA eligibility: patient is on apixaban → CONTRAINDICATION to tPA (alteplase). Cannot give IV thrombolytic while on anticoagulant
Blood pressure management for mechanical thrombectomy: lower SBP to <185 and DBP to <110. Administer IV labetalol 10mg push (or nicardipine infusion). Monitor BP q5–10min
Activate neurointerventional team — patient has large vessel occlusion (left MCA) and is within 6-hour window for mechanical thrombectomy
Establish 2 IVs, draw labs: CBC, coagulation panel, type and screen, BMP
Continue cardiac monitoring — AFib is the likely cause (cardioembolic stroke). Monitor for new arrhythmias
Perform NIHSS assessment — score 12 = moderate stroke. Repeat after intervention
Monitor closely for neurological deterioration — repeat neuro exam q15 min initially
Prevent complications: keep NPO until swallow evaluation, elevate HOB 15–30°, maintain normoglycemia and normothermia
After thrombectomy: monitor BP closely (target <180/105 per orders), frequent neuro checks, watch for reperfusion injury and hemorrhagic transformation
Administer statin (high-dose atorvastatin 80mg) for plaque stabilization
Assess for aspiration risk — NPO until swallow screen passed. Dysarthria + facial droop = high aspiration risk
Initiate VTE prophylaxis (SCDs initially, then chemical prophylaxis after 24h if no hemorrhage)
Plan for early mobilization and physical/occupational/speech therapy evaluation

Patient Education

Stroke recovery varies — early rehabilitation (PT, OT, speech therapy) is crucial for optimal recovery
Medication education: anticoagulation adherence is critical — AFib was the likely cause. Review apixaban: take as scheduled, bleeding precautions, no double dosing
Recognize stroke warning signs: BE-FAST (Balance, Eyes, Face, Arm, Speech, Time)
Blood pressure management: keep BP controlled to prevent recurrent stroke
Diabetes, cholesterol, and smoking management: reduce modifiable risk factors
Swallow precautions: thickened liquids or pureed diet as recommended by speech therapy
Fall precautions: right-sided weakness increases fall risk. Use assistive devices
Support for family: stroke is overwhelming — provide emotional support and resources
Follow-up appointments: neurology, cardiology (AFib management), rehabilitation
Driving: assess safely — may need to refrain temporarily

Key Takeaways 💡

⭐ "Time is brain" — 1.9 million neurons die per minute during ischemic stroke. Rapid treatment is critical
⭐ tPA (alteplase) window: within 4.5 hours of LKN. Mechanical thrombectomy: within 6 hours (up to 24h with imaging criteria)
⭐ Patients on anticoagulants (apixaban, warfarin) are INELIGIBLE for tPA — mechanical thrombectomy is the option
⭐ Always check blood glucose first — hypoglycemia can mimic stroke symptoms exactly
⭐ BP must be <185/110 for tPA and thrombectomy — use labetalol or nicardipine for controlled lowering
⭐ AFib is the leading cause of cardioembolic stroke — anticoagulation adherence prevents recurrence
⭐ NIHSS score guides treatment: higher scores (≥6) with large vessel occlusion → consider thrombectomy

Patient Snapshot

Age/Sex: 76y Female