Discussion - tPA Stroke

We discussed risks, benefits and alternatives to tPA with the [patient/family] at this time.  We specifically discussed the results of the NINDS study which suggested that 8 out of 18 stroke patients who receive tPA according to a strict protocol will recover by 3 months after the event without significant disability.  We discussed that this is compared to 6 out of 18 stroke patients (one-third) who recover substantially regardless of treatment.

We discussed that tPA has potential risks, which include bleeding into the brain, other types of serious bleeding, and even death that vary by studies.  We discussed the following risks:

-The NINDS study suggested that bleeding into the brain occurred in about 1 out of 18 patients receiving tPA (specifically, 5.8%).  When this occurred, there was a 45% fatality rate.

-Several studies suggested treatment with “clot-dissolving” medications increases the number of patients who die following a stroke.

-Subsequent studies demonstrated that using tPA more liberally than is recommended in NINDS protocol resulted in a higher rate of intracranial hemorrhage.

We also discussed that tPA complications are more likely in patients over 70 years of age, those with more severe stroke (NIHSS over 15), or those with an elevated blood glucose (specifically >300 mg/dL).  After discussion of these risks, the [patient/family] wished to [be treated with tPA/refuse treatment with tPA].

https://www.aaem.org/UserFiles/file/tpaedtool-AAEM.pdf

Decision Rule - NIH Stroke Scale

NIH Stroke Scale

1A: Level of consciousness (may be assessed casually while taking history)

-          Alert; keenly responsive  . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Arouses to minor stimulation . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Requires repeated stimulation to arouse  . . . . . . . . . . . .  [+2 points]

-          Movements to pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Postures or unresponsive . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

1B: Ask month and age

-          Both questions right  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          1 question right  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          0 questions right   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Dysarthric/intubated/trauma/language barrier  . . . . . . .  [+1 point]

-          Aphasic  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

1C: ‘Blink eyes’ & ‘squeeze hands’ (pantomime commands if communication barrier)

-          Performs both tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Performs 1 task   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   [+1 point]

-          Performs 0 tasks  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

2: Horizontal extraocular movements (only assess horizontal gaze)

-          Normal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Partial gaze palsy; can be overcome . . . . . . . . . . . . . . . . .  [+1 point]

-          Partial gaze palsy; corrects with oculocephalic reflex . . .  [+1 point]

-          Forced gaze palsy; cannot be overcome   . . . . . . . . . . . . .  [+2 points]

3: Visual fields

-          No visual loss   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Partial hemianopia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Complete hemianopia   . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Patient is bilaterally blind . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

-          Bilateral hemianopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

4: Facial palsy (use grimace if obtunded)

-          Normal symmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Minor paralysis (flat nasolabial fold, smile asymmetry . .  [+1 point]

-          Partial paralysis (lower face)  . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Unilateral complete paralysis (upper/lower face)  . . . . . .  [+3 points]

-          Bilateral complete paralysis (upper/lower face) . . . . . . . .  [+3 points]

5A: Left arm motor drift (count out loud and use your fingers to show the patient your count)

-          No drift for 10 seconds  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Drift, but doesn’t hit the bed  . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Drift, hits bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Some effort against gravity   . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          No effort against gravity . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

-          No movement  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+4 points]

-          Amputation/joint fusion . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

5B: Right arm motor drift (count out loud and use your fingers to show the patient your count)

-          No drift for 10 seconds  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Drift, but doesn’t hit the bed  . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Drift, hits bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Some effort against gravity   . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          No effort against gravity . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

-          No movement  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+4 points]

-          Amputation/joint fusion . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

6A: Left leg motor drift (count out loud and use your fingers to show the patient your count)

-          No drift for 10 seconds  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Drift, but doesn’t hit the bed  . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Drift, hits bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Some effort against gravity   . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          No effort against gravity . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

-          No movement  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+4 points]

-          Amputation/joint fusion . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

6B: Right leg motor drift (count out loud and use your fingers to show the patient your count)

-          No drift for 10 seconds  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Drift, but doesn’t hit the bed  . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Drift, hits bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Some effort against gravity   . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          No effort against gravity . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

-          No movement  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+4 points]

-          Amputation/joint fusion . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

7: Limb ataxia (finger-nose-finger and heel-shin tests)

-          No ataxia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Ataxia in 1 limb  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Ataxia in 2 limbs  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Does not understand  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Paralyzed  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Amputation/joint fusion . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

8: Sensation

-          Normal; no sensory loss  . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Mild-moderate loss: less sharp/more dull . . . . . . . . . . . . .  [+1 point]

-          Mild-moderate loss; can sense being touched  . . . . . . . . .  [+1 point]

-          Complete loss; cannot sense being touched at all  . . . . . .  [+2 points]

-          No response and quadriplegic   . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Coma/unresponsive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

9: Language/aphasia (describe the scene; name the items; read the sentences (standard printouts))

-          Normal; no aphasia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Mild-moderate aphasia  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

(some obvious changes without significant limitation)

-          Severe aphasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

(fragmentary expression, inference needed, cannot identify materials)

-          Mute/global aphasia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

(no usable speech/auditory comprehension)

-          Coma/unresponsive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

10: Dysarthria (read the words (standard printouts))

-          Normal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Mild-moderate dysarthria  . . . . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

(slurring but can be understood)

-          Severe dysarthria  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

(unintelligible slurring or out of proportion to dysphagia)

-          Mute/anarthric  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

(no usable speech/auditory comprehension)

-          Intubated/unable to test   . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

11: Extinction/inattention

-          No abnormality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Visual/tactile/auditory/spatial/personal inattention  . . . .  [+1 point]

-          Extinction to bilateral simultaneous stimulation . . . . . . . .  [+1 point]

-          Profound hemi-inattention  . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

(example: does not recognize own hand)

-          Extinction to >1 modality  . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

TOTAL SCORE = [##]

An NIH stroke scale score of 0-4 is consistent with minor stroke. 

An NIH stroke scale score of 5-15 is consistent with moderate stroke. 

An NIH stroke scale score of 16-20 is consistent with moderate-severe stroke. 

An NIH stroke scale score of 21-42 is consistent with severe stroke.

https://www.mdcalc.com/nih-stroke-scale-score-nihss
https://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss
https://www.mdcalc.com/hat-hemorrhage-thrombolysis-score-predicting-post-tpa-hemorrhage
https://www.mdcalc.com/sedan-score-post-tpa-hemorrhage

MDM - Ischemic Stroke

[##]-year-old [male/female] with [headache/weakness/slurred speech] with history and exam consistent with [acute/subacute] ischemic stroke [involving NAME territory].

Initial considerations in this patient included cerebrovascular accident (CVA) from ischemic and hemorrhagic etiologies, metabolic etiologies including hypoglycemia, hyponatremia, and hyperglycemia amongst others, intracranial mass including tumor, seizure, systemic infectious processes, and conversion disorder among others.

Patient presented with complaint of [headache/weakness/slurred speech/facial droop/vision loss] with reported onset of symptoms [## hours prior to presentation/unknown].  Patient noted to have an NIH stroke scale of [##] on arrival in the ED.  Patient noted to be [out of/within] window for thrombolytics.  A Code Stroke was [not] activated in the ED.  A non-contrast CT scan of the head was obtained with no evidence of intracranial hemorrhage.  Additional imaging was obtained to include [a CTA of the head and neck/MRI] and was [notable for FINDINGS].

Patient noted to have symptoms consistent with likely [right/left anterior cerebral artery (ACA) distribution stroke based on contralateral sensory and motor symptoms in the lower extremities (sparing hands and face), gait apraxia (Left ACA: akinetic mutism, transcortical motor aphasia (similar to Broca’s aphasia); Right ACA: confusion, motor hemineglect)/right/left middle cerebral artery (MCA) stroke based on contralateral hemiparesis, facial plegia, and sensory loss with motor deficits affecting the face and upper extremities more than the lower extremities (dominant hemisphere involvement resulting in aphasia (Wernicke’s (receptive) aphasia or Broca’s (expressive) aphasia/non-dominant hemisphere involvement resulting in dysarthria (motor deficit of the mouth with understanding intact) and inattention and neglect on side opposite to lesion, agnosia (inability to recognize previously known objects)/right/left posterior circulation stroke based on dizziness, dysarthria, dystaxia, diplopia, and dysphagia].  Labs obtained to include point-of-care glucose, CBC, chemistry, coagulation panel [additional] and were [unremarkable/notable for leukocytosis and left shift].  We considered stroke mimics, including Todd’s paralysis after seizure, complex migraine, pseudoseizure and conversion disorder, unlikely based on history, exam, labs, and imaging.

Neurology was consulted on the patient and involved in the decision-making regarding administration of tPA.  We considered administration of tPA in this patient, and felt it was [indicated/contraindicated] based on [presentation within 3/4,.5 hours from onset of symptoms with no contraindications to treatment/presentation over 3/4.5 hours from onset of symptoms/absolute evidence of intracranial hemorrhage on CT/clinical presentation suggestive of subarachnoid hemorrhage (SAH)/neurosurgery, head trauma or stroke within the past 3 months/uncontrolled hypertension (≥185 mmHg systolic blood pressure or >110 mmHg diastolic blood pressure/history of intracranial hemorrhage/known intracranial arteriovenous malformation, neoplasm or aneurysm/active internal bleeding/suspected or confirmed endocarditis/known bleeding diathesis ((1)platelet count <100,000; (2)patient has received heparin within 48 hours and has an elevated aPTT (greater than upper limit of normal for lab); (3)current use of oral anticoagulants (e.g. warfarin) and INR >1.7; (4)current use of direct thrombin inhibitors or direct factor Xa inhibitors)/abnormal blood glucose (<50 mg/dL)/relative presence of only minor or rapidly improving symptoms/major surgery or serious non-head trauma in the previous 14 days/history of gastrointestinal or urinary tract hemorrhage within 21 days/seizure at stroke onset/recent arterial puncture at a non-compressible site/recent lumbar puncture/post myocardial infarction (MI) pericarditis/pregnancy].  We discussed risks, benefits and alternatives to administration of tPA with the [patient/family] and they [provided verbal/written consent/wished to refuse this treatment].

Prior to treatment with tPA, blood pressure was noted to be [less than 185 mmHg systolic and 110 mmHg diastolic/noted to be greater than 180 mmHg systolic/110 mmHg diastolic which prompted treatment with Nicardipine/Labetalol with/without noted improvement in blood pressure].  We monitored the patient for complications post-tPA administration, and discussed with ICU team for admission.

https://wikem.org/wiki/Ischemic_stroke
https://www.mdcalc.com/nih-stroke-scale-score-nihss
https://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss
https://www.mdcalc.com/hat-hemorrhage-thrombolysis-score-predicting-post-tpa-hemorrhage
https://www.mdcalc.com/sedan-score-post-tpa-hemorrhage
https://www.mdcalc.com/tpa-tissue-plasminogen-activator-dosing-stroke-calculator