This patient should undergo repeat noncontrast CT of the head. She had an ischemic stroke that was likely due to subtherapeutic anticoagulation. Findings from physical examination, notably an elevated National Institutes of Health Stroke Scale (NIHSS) score, and the initial CT scan of the head suggest a large cerebral infarction in the entire territory of the left middle cerebral artery. She was appropriately given intravenous recombinant tissue plasminogen activator within the recommended treatment window because of the high risk of a poor neurologic outcome. At the time of treatment, she did not meet any exclusion criterion for thrombolysis, such as an elevated blood pressure or an INR greater than 1.7. The patient has several risk factors for intracerebral hemorrhage after thrombolysis, including a high NIHSS score and a cardioembolic cause of the stroke. Any change in the neurologic examination, particularly in patients treated with thrombolysis, should prompt consideration of hemorrhage, which is associated with a high mortality rate. Hemorrhage after thrombolysis can be detected on a noncontrast CT scan of the head.

Intra-arterial thrombectomy is inappropriate in this patient. The new right-leg paralysis noted in the second neurologic examination is most concerning for intracerebral hemorrhage after thrombolysis. However, the benefit of intra-arterial treatment modalities, after or instead of intravenous thrombolysis, has not been established in randomized clinical trials.

This patient also should not be given intravenous labetalol. Administering treatment to lower her blood pressure is inappropriate because her blood pressure is already less than the recommended target of 180/105 mm Hg after thrombolysis.

Aspirin is appropriate stroke therapy in patients not eligible for thrombolysis and can be administered rectally in patients who are unable to swallow. However, in patients who have received thrombolysis, early administration of antiplatelet agents can increase the risk of hemorrhage. In addition, although aspirin is associated with a reduction in recurrent stroke risk when administered within 48 hours of ischemic stroke onset, aspirin has not been shown to prevent or reverse neurologic worsening.