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When not to treat.. and what not to do…

When not to treat.. and what not to do…. Western Stroke Day Nov, 30, 2012 Negar Asdaghi MD FRCPC. Mr PS. 81 year old, RHD retired family doctor Presented with sudden onset of left sided weakness within 2.5hr of onset. PMH. HTN DM Dyslipidemia CAD (stent 2001 )

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When not to treat.. and what not to do…

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  1. When not to treat..and what not to do… Western Stroke Day Nov, 30, 2012 Negar Asdaghi MD FRCPC

  2. MrPS • 81 year old, RHD retired family doctor • Presented with sudden onset of left sided weakness within 2.5hr of onset

  3. PMH • HTN • DM • Dyslipidemia • CAD (stent 2001) • Atrial fibrillation (not currently on OAC) • Previous history of ICH (2001 AAICH (INR=8.9), 2008 spontaneous IVH) • CRF

  4. Rx Med: ASA 81 mg/daily Ramipril 5mg/daily Diltiazem180 mg/daily Simvastatin 40 mg/daily Metformin 500/BID

  5. HPI Continued.. • Developed sudden onset of left sided weakness (F/A/L) associated with some confusion • No history of trauma, no seizure like activity

  6. Exam • SBP=165-170, HR= irregular, 100-120 • Dense gaze preference to the right • left HHA • left sided neglect • left UMN facial weakness • Left arm and leg 0/5 • Upgoing plantar response on the left • NIHSS=21

  7. What to do..? • 2.5 hrs into a large acute Rt MCA stroke • Prior history of ICH • No other contraindications • 12:30 a.m.

  8. Exclusion Criteria for tpa Adams et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary, 2007

  9. 5594 IV-tpa treated patients, 34.3% off label use 422 IV-tpa treated patients, 55% off label use

  10. 1105 patients were thrombolyzed • 51% of thrombolytic cases were off label • 33% had two concomitant contraindications • 3% had 3 concomitant contraindications • 3 patients had prior ICH, SAH • The only independent factor associated with poor outcome was age>80

  11. Commonest reasons for of off-label use of tpa: • Age>80 • Minor stroke (NIHSS<5) • Late treatment >3hr • BP>185/110 • Anti-coagulation

  12. Canadian data on off label use of tPA Treat fist ask questions later

  13. Ultimate Decision?

  14. Treatment • IV tpa started • Angio suite staff on route • Patient started moving his left arm within 20 min of infusion • By the time of puncture the only deficits were left HHA and some minor drift

  15. Course in the hospital • NIHSS at 24 hours was 2 • No bleeding

  16. Discharge • Doing well • CrCl ≈30 • Decision to start Anti-coagulation?

  17. OAC Canadian best practice recommendations, 2012

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