When not to treat.. and what not to do…

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