09-05-2011, 02:10 PM
A 62-year-old woman with a 3-year history of chronic atrial fibrillation developed acute expressive aphasia and moderate right upper extremity weakness shortly after eating breakfast at 8:00 am . Her husband immediately called the paramedics, who transported the patient to the emergency department. Upon arrival at 8:20 AM , the patient is alert but mute. She follows all commands appropriately during the physical examination. Blood pressure is 150/88 mm Hg. Atrial fibrillation is present with a controlled rate of 86/min. She has 3/5 weakness in the right upper extremity, a mild right facial droop, and an extensor plantar response on the right. Screening laboratory studies are normal except for a prolonged international normalized ratio of 1.3 (she was on warfarin therapy). Chest radiograph is normal. A CT scan of the brain without contrast shows loss of the gray-white interface at the left frontal operculum.
Which of the following is the most appropriate treatment?
(A) Intravenous tissue plasminogen activator
(B) Intravenous heparin bolus followed by intravenous heparin infusion
© Intravenous heparin infusion without initial heparin bolus
(D) Aspirin, 325 mg daily, plus dipyridamole, 200 mg twice daily