March 2015

65-year-old female with aphasia and right hemiplegia

History and Examination

  • 65-year-old F s/p endoscopic laparoscopic cholecystectomy 4 days prior
  • Last seen normal at 10 pm when she went to sleep
  • She awoke at 2 am and her husband noted she was aphasic and right hemiplegic
  • Called 911 and arrives to the ED at 3 am
  • CTA completed at 3:15 am
  • PMH: asthma, hypertension, arthritis, chronic low back pain
  • PSH: endoscopic laprascopic cholycystectomy 4 days prior
  • Meds: advair, albuterol, atorvastatin, lisinopril

Exam 35.8 C HR 94 BP 165/100 RR 23

1a.     Level of Consciousness:            
2=not alert, requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped)     

1b.     LOC Questions to month and age:         
2 = Answers neither question correctly.     

1c.     LOC Commands to open/close eyes & open/close grip:   
2=Performs neither task correctly

2.     Best Gaze:               
0=normal     

3.     Visual:                 
0=No visual loss  

4.     Facial Palsy:                 
0=Normal symmetric movement     

5a.     Motor Left Arm             
1=Drift, limb holds 90 (or 45) degrees but drifts down before full 10 seconds: does not hit bed     

5b.     Motor Right Arm             
3=No effort against gravity, limb falls  
  
6a.     Motor Left Leg             
1=Drift, limb holds 90 (or 45) degrees but drifts down before full 10 seconds: does not hit bed     

6b.     Motor Right Leg             
3=No effort against gravity, limb falls     

7.     Limb Ataxia:                 
0=Absent     

8.     Sensory:                 
1=Mild to moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; there is a loss of superficial pain with pinprick but patient is aware She is being touched     

9.     Best Language:             
2 = Severe aphasia; all communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener. Range of information that can be exchanged is limited; listener carries burden of communication. Examiner cannot identify materials provided from patient response.     

10.     Dysarthria:                 
2=Severe; patient speech is so slurred as to be unintelligible in the absence of or our of proportion to any dysphagia, or is mute/anarthric     

11.     Extinction/Neglect:           
0=No abnormality     
                    

Total NIHSS Score:

Figure 1 CTA

Figure 2 CT Perfusion

 
1. Does this patient meet the time window for IV tPA?
2. What would be your next step in management?
3. Evidence in favor of IV tPA in eligible patients is:
4. Evidence in favor of endovascular intervention in eligible patients is:
5. Which of the following describes you?
6. I practice in one of the following locations.
7. Comments
  • After wrking decades without handling Cerebrovascular cases, having no facilities either- needed this refreshment got through the Case History. Thanks.

Case Explanation

The stroke onset time for wake-up strokes for IV tPA eligibility is determined from the last seen normal time, therefore in this patient, her stroke onset was 10:00pm.  Her stroke duration is 5 hours 15 minutes which is outside the time window for IV tPA.
This patient is ineligible for IV tPA because of her stroke duration, as well as her recent abdominal surgery 4 days prior.
Since she is not a candidate for IV tPA, the best option for next step in management would be endovascular intervention.
The evidence for IV tPA for acute stroke is Level 1 randomized controlled trial. The NINDS rt-PA Stroke Trial demonstrated better mRS outcomes at 90 days in patients that were randomized to rt-PA over patients randomized to placebo.
The evidence for endovascular intervention for acute stroke is Level 1 randomized clinical trials.  Previous clinical trials failed to demonstrate a benefit for endovascular intervention, however, more recent randomized clinical trials, MR CLEAN, ESCAPE, and EXTEND-IA trials demonstrate better mRS outcomes at 90 days in patients that were randomized to endovascular intervention over patients randomized to standard care. 

References

  • Tissue Plasminogen Activator for Acute Ischemic Stroke The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group N Engl J Med 1995; 333:1581-1588 December 14, 1995DOI: 10.1056/NEJM199512143332401
  • A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke Olvert A. Berkhemer, et al, for the MR CLEAN Investigators N Engl J Med 2015; 372:11-20 January 1, 2015DOI: 10.1056/NEJMoa1411587
  • Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke Mayank Goyal, et al for the ESCAPE Trial Investigators February 11, 2015DOI: 10.1056/NEJMoa1414905
  • Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection Bruce C.V. Campbell, et al, for the EXTEND-IA Investigators February 11, 2015DOI: 10.1056/NEJMoa1414792

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