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When not to treat.. and what not to do…. Western Stroke Day Nov, 30, 2012 Negar Asdaghi MD FRCPC. Mr PS. 81 year old, RHD retired family doctor Presented with sudden onset of left sided weakness within 2.5hr of onset. PMH. HTN DM Dyslipidemia CAD (stent 2001 ) - PowerPoint PPT Presentation
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Western Stroke DayNov, 30, 2012
Negar Asdaghi MD FRCPC
When not to treat..and what not to do…
Mr PS
• 81 year old, RHD retired family doctor
• Presented with sudden onset of left sided weakness within 2.5hr of onset
PMH
• HTN• DM• Dyslipidemia• CAD (stent 2001)• Atrial fibrillation (not currently on OAC)• Previous history of ICH (2001 AAICH (INR=8.9),
2008 spontaneous IVH)• CRF
Rx
Med:
ASA 81 mg/dailyRamipril 5mg/dailyDiltiazem180 mg/dailySimvastatin 40 mg/dailyMetformin 500/BID
HPI Continued..
• Developed sudden onset of left sided weakness (F/A/L) associated with some confusion
• No history of trauma, no seizure like activity
Exam• SBP=165-170, HR= irregular, 100-120
• Dense gaze preference to the right• left HHA• left sided neglect• left UMN facial weakness• Left arm and leg 0/5• Upgoing plantar response on the left• NIHSS=21
What to do..?
• 2.5 hrs into a large acute Rt MCA stroke• Prior history of ICH • No other contraindications• 12:30 a.m.
Adams et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary, 2007
Exclusion Criteria for tpa
5594 IV-tpa treated patients, 34.3% off label use
422 IV-tpa treated patients, 55% off label use
• 1105 patients were thrombolyzed• 51% of thrombolytic cases were off label• 33% had two concomitant contraindications• 3% had 3 concomitant contraindications• 3 patients had prior ICH, SAH• The only independent factor associated with
poor outcome was age>80
• Commonest reasons for of off-label use of tpa:
• Age>80• Minor stroke (NIHSS<5)• Late treatment >3hr• BP>185/110• Anti-coagulation
Canadian data on off label use of tPA
Treat fist ask questions later
Ultimate Decision?
Treatment
• IV tpa started• Angio suite staff on route• Patient started moving his left arm within
20 min of infusion• By the time of puncture the only deficits
were left HHA and some minor drift
• NIHSS at 24 hours was 2• No bleeding
Course in the hospital
Discharge
• Doing well• CrCl ≈30• Decision to start Anti-coagulation?
Canadian best practice recommendations, 2012
OAC
Summary
• Off label use of tpa is common• Difficult stroke scenarios occur frequently
• You have to know the rules to break them