This patient should receive intravenous recombinant tissue plasminogen activator (rtPA). He is within the 3-hour window for treatment of patients who do not meet any of the exclusion criteria for thrombolysis. In the National Institute of Neurological Diseases and Stroke (NINDS) rtPA trial, patients who received intravenous rtPA within 3 hours of stroke onset had a greater likelihood of clinical improvement at 3 months compared with those who received placebo. The trial included patients with atrial fibrillation and all ischemic stroke subtypes and showed no significant safety difference between stroke subtypes. Because he has no contraindications to thrombolysis, it is the treatment of choice in this patient.

High-dose (325-mg) aspirin would be an appropriate initial treatment if the patient met any of the exclusion criteria for thrombolysis, which he does not. As long as a follow-up CT scan of the head shows no hemorrhage, aspirin should be initiated 24 hours after administration of rtPA.

Hyperglycemia is common in patients with acute ischemic stroke and, if persistent in the first 24 hours after stroke onset, is associated with poor functional outcomes. To date, no definitive clinical trials have outlined the best approach to treatment or the most appropriate targets. Acute ischemic stroke guidelines are thus in keeping with general recommendations for all critically ill hospitalized patients who have mild hypertension, with or without diabetes mellitus, which are not to use intensive insulin therapy to normalize plasma glucose levels. If insulin therapy is required, the American College of Physicians recommends target plasma glucose levels of 140 mg/dL to 200 mg/dL (7.8-11.1 mmol/L) while monitoring carefully for hypoglycemia. Insulin therapy is thus not indicated in this patient whose plasma glucose level falls in the target range.

Intravenous heparin does not reduce the 14-day risk of recurrent stroke or mortality in patients with atrial fibrillation who have a new stroke and is therefore not indicated.