Mayo Clinic Consultation: Subject D-B

Keywords

We have a 54 year old woman who developed left sided hemiplegia at 0830 after waking. Her past history is positive for smoking and hypertension. She has received labetolol in the emergency dept to lower her BP from 190/89 and is now at 159/74. HR = 74 and normal sinus. She is not on any blood thinners. She has no contraindications to tpa therapy. We are requesting an acute stroke neurology consultation to determine the appropriateness of tpa therapy.

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Case Comments:

  • 28 Aug 2009 12:18

    Dr. Vail, thank you for the telestroke consultation. You describe a 54 year old female with vascular risk factors of smoking and hypertension who sustained an acute onset of left sided hemiplegia at a precise time of 0830AM and presents to your ED < 3 hrs after stroke onset. After IV Labetalol administration her BP responded nicely and is definitely < 185/110 threshold. Her estimated NIHSS score is approximately Gaze 1 (partial gaze palsy), Facial palsy 2, Motor arm 3, Motor leg 2, Dysarthria 1 = 8. We have clarified, by telephone, the issue of extinction and neglect, possible visual/spatial neglect. NIHSS = 10.

    #1
  • 28 Aug 2009 12:41

    You have carefully indicated that she has no clinical or laboratory contraindications to IV tPA. I understand that she has had unenhanced CT head as well as CT perfusion studies. Could you please upload the neuroimaging for my review?

    #2
  • 28 Aug 2009 12:44

    Certainly

    #3
  • 28 Aug 2009 12:47

    Dr. Vail, I have reviewed the diagnostic neuroimaging. She appears to have no radiologic contraindications for IV tPA.

    #4
  • 28 Aug 2009 13:01

    The patient still has the same neurological deficits. The perfusion study was performed at 1105 and we might be reaching the end of the 3 hour window. What should we do?

    #5
  • 28 Aug 2009 13:17

    The Stroke Council of AHA/ASA has issued an advisory statement based on the published ECASS III trial recommending an expanded time window for treatment of acute ischemic stroke with IV tPA. [I send you via email 3 resources of education material, power point slides, statement, and top ten list].

    #6
  • 28 Aug 2009 13:17

    Your patient meets eligibility criteria for the expanded time window. I would recommend preparing the IV tPA 0.9 mg/kg (max 90 mg) and administer 10% as bolus over 1 minute; with remainder as infusion over 60 minutes. Please proceed. Unless there are any additional questions, I will dictate consult note, have it transcribed, and e-fax to you immediately.

    #7