tPA Not Indicated for Stroke Patient

Case involves a 74 y/o male who became dizzy with left sided weakness at home when getting up from bed. He fell into the bed post, injuring his eyebrow w/ bleed on 6/25/09 at approximately 3:48 am. Ambulance was called and he advised EMS that he had noticed left sided arm & leg weakness & left facial droop w/ slurred speech at that time. He was taken by ambulance to the Hospital where the records reflect he was sent for CT scan.

Subsequent to the CT, his symptoms temporarily resolved and he was able to move his left arm. Then suddenly approx 15 minutes later he developed symptoms again, including left tongue deviation, left facial droop, L sided paralysis, weakness, difficulty lifting w/ L arm. No tPA was given according to the records because the physicians evaluating him felt that he had the prior resolution of symptoms. The stroke team was called and they decided to start him on Heparin. A cardiovascular assessment noted afib on CM with no history of irregular heartbeat. Electrocardiogram showed afib w/ LVH. CT of the brain revealed no intracranial hemorrhage. His symptoms seemed to continue to reappear, then disappear, reappear and the impression was a CVA. They felt they would now start Coumadin dosing for DVT.

The CT scan of 6/25/09 revealed old L Basilar ganglia/Lentiform Nucleus infarct & periventricular white matter changes w/o evidence of acute parenchymal hemorrhage, edema or mass effect. It appears that he subsequently had a further CT scan on 6/27/09 which revealed an acute infarct now in the right pons. Ultrasound of the lower extremities revealed no evidence of DVT. On 7/1/09, the patient had ICD placed. Regadenson perfusion study was performed 7/1/09 and revealed evidence of infarction in the LAD and RCA territories. Gated analysis revealed multiple regional abnormalities (ejection fraction of 20% post stress) and a fixed antero-septal apical defect of severe intensity consistent w/ infarction . He was ultimately discharged to a rehab but continued w/ left sided weakness and paralysis. We would appreciate your opinion on the care rendered to this gentleman as he believes he wasn’t treated appropriately for a possible stroke.

MEDQUEST EXPERT RESPONSES:

tPA is indicated in new lesions and would probably be off label in the time frame you sketched out. He presented with what sounded like a TIA with atrial fib which was correctly treated with heparin. After 3 hours post event there is no approval for tPA use and after 5 hours even little data especially for what seems like a pontine stroke. As to whether it would have helped it’s difficult to say as I assume there are no before infarct scans. Unlikely the outcome would have been different. 

– Dr AT, Neurologist

The key to this case is the initial “improvement”. If the arm got better, but the face and speech didn’t resolve completely, then he was never going to be a candidate for tPA as the damage was done software task management

– Dr DB, Neurologist