Treating Stroke… June 26, 2012

Posted by Andy Jagoda, MD in: Neurologic , trackback

A 64-year-old male presents to the ED with the acute onset of profound right-sided motor weakness and expressive aphasia. The patient has no headache, no history of trauma, and no other problems upon presentation. His only chronic medical problem is hypertension that is well controlled on his medications. His wife witnessed the onset of his symptoms while they were eating dinner 3.5 hours prior to arrival. He has normal vital signs, and a stat CT scan of the head is normal as are his laboratory studies. His deficits have persisted throughout his expedited workup and he is now 4 hours into an acute ischemic stroke (an hour beyond the FDA-approved treatment window for intravenous rt-PA), with a calculated NIHSS score of 16.

What emergent treatment options, if any, do you have for this patient?

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Comments »

1. Dr.Adel Noman - June 27, 2012

according to the medical history(HTN) AND the symptoms and NIHSS score of 16 this employee has ischemic stroke (middle cerrebral artey?)despite the CT -scan results because it early stroke and always cannot see the ischemic area in the brain ,and this patient need also for full neurologcal examination
to confirm the diagnosis and exclude the other diseases.

despite the time now 4 hour after the onest of stroke and according to the american heart association and american stroke association was exten the time from 3hour-4,5hour to give thrombolytic (rt-PA) TO ISCHEMIC STOKE.

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3. Nicolas Peschanski - June 28, 2012

Looking for indirect brain CT Scan signs
Best option should be Brain MRI with T1/T1 Echo/FLARE/ARM/TOF
t-Pa in Stroke ICU ward or ER with telemedicine neurovasc expert

4. MENFIL ORELLANA - July 1, 2012

If available and imaging does not preclude, intra-arterial thrombolysis is an option after urgent MRI studies including vascular studies. Also must have carotid doppler and echocardiogram done urgently and blood drawn to investigate causes of cryptogenic stroke because he does not have apparent risk factors. The sudden onset while eating correlates with embolism.

5. ghaleb - July 1, 2012

this patient has ischemic stroke in the anterior circulation,the time interval for the thrompolytic therapy is extended to 4,5 hours,he should be evaluated, if no contraindications thrombolytics should be offered to him by expert neurologist and protocolized practice

6. Ibrahim Showaihi - July 1, 2012

this patient suffering acute ischemic stroke
we know for the last few years the time window for use of fibrinolytic therapy in stroke patient was extended to 4.5 hour and even there is on goning research to extend it even further to 6 hours
if this patient is being treated in hospital with stroke team and stroke unit used to treat stroke patient with fibrinolytic therapy
this may benefit from fibrinolytic therapy if no contraindication

7. Rauvan Averick - July 1, 2012

Evidence for tPA efficacy after 3 hrs is shaky. Intraaterial thrombolytics or thrombectomy – maybe.

8. dr. ashok mishra - July 2, 2012

patient must rush for MRI/MRA brain if CAB is stable and doctors must get ready for tpa ( intra arterial ) if required

9. dr suresh naidu - July 2, 2012

agree with Dr Adel….this patient is should be thrombolysed as per new AHA and ASA guidelines

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