Brain Attack

It is Monday morning and you have been assigned the following case: a 76-year-old woman presenting for an elective hemicolectomy with a past medical history of hypertension, chronic atrial fibrillation (anticoagulation therapy with Coumadin discontinued five days before surgery) and stroke without residual neurologic deficit. The intraoperative course was complicated by episodic hypotension, which was treated with bolus doses of phenylephrine, and atrial fibrillation with rapid ventricular response, which was treated with five milligrams of intravenous metoprolol. Emergence from anesthesia and clinical course in the postanesthesia care unit were uneventful. However, on postoperative day one, the patient was observed to have a new-onset left-sided hemiparesis. A non-contrast computed tomography scan ruled out intracranial hemorrhage and magnetic resonance imaging (MRI) revealed an acute ischemic stroke in the right middle cerebral artery distribution. The patient was taken emergently to the interventional...