Stroke – Current Criteria for Dx and Treatment

MEDQUEST NEUROLOGIST DISCUSSES CURRENT CRITERIA FOR DIAGNOSING AND TREATING STROKE

 

The major liability issues regarding stroke revolve around the use of tPA (tissue plasminogen activator…clot busting drug).  Not administering the drug for a qualified patient may likely constitute a departure from good and accepted practice.

There are published criteria for the use of tPA ( American Heart Association ). tPA can be initiated within 3 hours of onset of stroke; poor documentation in the chart of time of onset makes the physician particularly vulnerable. Failure to consult family members as to time of onset can lead to mistakenly withholding tPA.  It has become more common to find cases where tPA was withheld than cases where it was given inappropriately (against the AHA guidelines).  The major risk factor is bleeding into the brain. As of 2009, tPA may now be used up to 4.5 hours after onset of stroke.

The efficacy of tPA as initially reported was 30-38%, thus depriving a patient the opportunity of a better outcome.  A retrospective statistical review posits that the rate of improvement is actually 60%, i.e. more likely than not to have a better outcome.

The lack of administration of heparin/coumadin is more problematic. Coumadin is standard of care for cardiac sourced emboli to the brain (atrial firbrillation, ventricular aneurysm with clot). It is not currently proven to be of value for other types of stroke, TIA or stroke in evolution. However, liability may ensue from withholding coumadin (such as for dental surgery) and never re-instituting it, resulting in stroke.

TIA’s have received a great deal of attention in the most recent medical literature. TIA may be considered a medical emergency as the risk of stroke in the immediate following days is high. TIA’s are treated with aspirin, plavix or aggrenox (except cardiac sources = heparin/coumadin). Appropriate work-up may discover a severe carotid stenosis, which may be treated by surgery. Note that platelet inhibitors such as aspirin are statistically effective at about 30%, and there is little difference among them.

A relatively new issue is the risk of HIT…heparin induced thrombocytopenia. Failure to recognize this entity can result in thromboses of cerebral veins and arteries and stroke.

Although rare, PRES (posterior reversible encephalopathy syndrome) if untreated, can result in stroke. PRES is seen in pre-eclamptic/eclamptic women and requires aggressive blood pressure management. Stroke usually results in blindness due to the posterior brain location of this under recognized obstetrical problem.