What to do now

• If there is any ongoing or new weakness, facial droop, speech difficulty, confusion, severe headache, drowsiness, imbalance, or vision loss: call emergency services / go to an emergency stroke center immediately. Do not drive.
• Do not start aspirin, clopidogrel, warfarin, apixaban, rivaroxaban, heparin, or other blood-thinning medicine on your own. The MRI mentions bleeding within the infarct, so the stroke team must decide if and when these are safe.
• Do not give food, water, or tablets by mouth until a swallow assessment has been done, due to aspiration risk.

Likely hospital treatment plan

1. Admission to a stroke unit, frequent neurological observations, blood pressure, oxygen, temperature, and glucose management.
2. Immediate vessel and cause assessment: CT/CT angiography of head and neck, ECG and continuous rhythm monitoring for atrial fibrillation, echocardiography, carotid imaging, blood tests including lipids and diabetes testing.
3. Repeat brain CT/MRI to ensure the small hemorrhagic transformation is stable before beginning antiplatelet or anticoagulant treatment.
4. Clot-removal treatment (mechanical thrombectomy) may be considered only if a major blocked brain artery is found and the patient meets time and imaging criteria. IV thrombolysis is generally a time-sensitive decision and may not be appropriate with current bleeding on imaging, but only the treating stroke specialist can determine this.
5. After stability is confirmed, secondary prevention is chosen based on the cause:
   • Antiplatelet medicine for many non-cardioembolic strokes.
   • Anticoagulation if atrial fibrillation or another cardiac clot source is found, but timing must be individualized because this is a sizeable infarct with hemorrhagic transformation.
   • High-intensity cholesterol-lowering treatment, and control of blood pressure, diabetes, smoking, and other risk factors.
6. Early physiotherapy, occupational therapy, speech/swallow therapy, and rehabilitation.