Mayo Clinic Consultation: Subject D-B
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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.
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?
28 Aug 2009 12:44
28 Aug 2009 12:47
Dr. Vail, I have reviewed the diagnostic neuroimaging. She appears to have no radiologic contraindications for IV tPA.
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?
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].
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.