Too Good To Treat

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Too Good To Treat?

• K Harkness

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History

• 80 year old R handed retired lorry driver
• Got up and felt well.
• After breakfast at 8am wife went to pack case,
  due to go on family holiday that day. Came back
  down stairs noted that her husband had weakness
  of mouth on L side, slumping to L side.
• Wife called 999
• Arrival at AE NGH 0920. Assessed 0930 L
  hemiparesis power 1/5 arm and leg.
• BP 130/60.BM 5.2 (NIHSS 9)

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Background

• PMH-Polio in 20s causing weak legs, but
  independent.
• Prev PAF-not on warfarin.
• Previous CVA 10 years ago complicated by partial
  seizures. COPD with recent chest infection
  needing in patient treatment
• No recent surgery
• No recent anticoagulation.
• PT 10.1, APTT 29.2

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Progress in AE

• CT Head 10am
• Seen in AE by stroke SpR 10am-L UMN facial
  weakness, L arm 4/5. Minor L sensory inattention.
• Clinical Imp R PACS as rapidly improving not for
  thrombolysis. ( NIHSS 5)
• D/W KAH-for transfer to neurology as if
  deteriorates for consideration of therapy

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CT Head 2 hours post onset
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Progress on neurology ward

• Arrived J2 11.40-able to lift arm against gravity
• Reassessment at 11.53-flicker of movement L arm,
  drowsy. NIHSS 12.00 9 randomised to IST3 with
  assent from wife.
• Time of bolus 12 20. 4 hours 20 mins post event
  onset. Door to needle time 3 hours 20 mins
• 2 hour NIHSS 8
• 24 hour NIHSS 13
• Transfer to B3 NIHSS 9

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CT Head 24 hours post treatment
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Poor Outcomes in Patients Who Do Not Receive
Intravenous Tissue Plasminogen Activator Because
of Mild or Improving Ischemic Stroke Eric E.
Smith, MD, FRCPC Abdul R. Abdullah, MD Iva
Petkovska, MD Eric Rosenthal, MD Walter J.
Koroshetz, MD Lee H. Schwamm, MD Stroke.
2005362497-2499.
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• Of 128 patients presenting within 3 hours, 41
  (34) were not given tPA because of mild or
  improving stroke.
• Of the TGT patients, 11 of 41 (27) died or were
  not discharged home because of neurological
  worsening (n6) or persistent mild neurological
  deficit (n5).
• There were 10 of 41 TGT patients (24) who had
  4-point improvement in NIH Scale score before tPA
  decision these patients were more likely to have
  subsequent neurological worsening (relative risk,
  4.1, 95 CI, 1.1 to 15.4 P0.05).

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Outcome of Stroke with Mild or Rapidly Improving
Symptoms Krassen Nedeltchev, MD Benjamin
Schwegler, BSc Tobias Haefeli, MD Caspar
Brekenfeld, MD Jan Gralla, MD Urs Fischer, MD
Marcel Arnold, MDLuca Remonda, MD Gerhard
Schroth, MD Heinrich P. Mattle, MD Stroke.
2007382531-2535
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• Seventy-five percent of patients with mild or
  rapidly improving symptoms will have a favorable
  outcome after 3 months. Therefore, a decision
  against thrombolysis seems to be justified in the
  majority of patients.
• However,selected patients, especially those with
  proximal vessel occlusions and baseline National
  Institutes of Health Stroke Scale scores 10
  points, might derive a benefit from thrombolysis

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Conclusions

• 25 of rapidly improving patients have a poor
  outcome
• Further studies are needed to identify those at
  high risk of deterioration so treatment can be
  given early.
• Possible tools include CTA,MRI Perfusion/diffusion
  mismatch,TCD

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