Alteplase for Posterior Circulation Ischemic Stroke at 45 to 24 Hours Quiz – ED

Mr. Chen is a 62-year-old Chinese male with a history of hypertension and hyperlipidemia who presents to the emergency department 10 hours after onset of dizziness, mild ataxia, and vertigo. His NIH Stroke Scale score is 3, indicating a mild stroke. Imaging confirms a posterior circulation ischemic stroke without extensive early hypodensity. He is not a candidate for thrombectomy. Current medications include amlodipine 5 mg daily and atorvastatin 20 mg nightly.

Question: Based on the latest evidence, what is the most appropriate pharmacologic intervention for Mr. Chen to improve his functional outcome?

Mrs. Li is a 70-year-old woman with mild posterior circulation ischemic stroke symptoms starting 18 hours ago. She has no contraindications for thrombolysis and her NIHSS score is 4. She is concerned about the risk of bleeding with alteplase therapy. Her current medications include aspirin 81 mg daily and lisinopril 10 mg daily.

Question: What information should the pharmacist provide regarding the safety profile of intravenous alteplase administered 4.5 to 24 hours after stroke onset in this patient?

Mr. Wang is a 58-year-old male presenting 20 hours after onset of mild dizziness and gait instability. Imaging shows no extensive early hypodensity. He has an NIHSS score of 7. He is not eligible for thrombectomy. The clinical team is considering intravenous alteplase. The pharmacist is asked to assist in evaluating patient suitability.

Question: Which factor should the pharmacist emphasize as critical in selecting Mr. Wang for alteplase therapy in the 4.5 to 24-hour window?