Treatment of Patients With Suspected Ischemic Stroke of Undetermined Onset and Negative Head Computed Tomography Scan

Abstract

This case represents a difficult situation; by the description, this woman probably has a multilobar cerebral infarction that is most likely secondary to an occlusion of the internal carotid artery or the proximal segment of the middle cerebral artery. The computed tomography scan is normal, a finding somewhat surprising given the severity of her stroke; the presence of a dense artery sign suggesting occlusion of the internal carotid or middle cerebral artery or early ischemic changes in the insular cortex would be expected. The absence of early ischemic changes suggests that the stroke might be of recent onset and potentially treatable. Although the National Institutes of Health Stroke Scale score is not provided in the vignette, the description suggests that her score would be at ≈20; it may be higher. This information is important because it portends a poor prognosis; she is likely to die or be disabled as a result of the stroke. The natural reaction is to prescribe reperfusion therapy to alter this otherwise potentially dismal situation.1 Still, caution should be exercised because the risk …