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

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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 ) - PowerPoint PPT Presentation


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Western Stroke DayNov, 30, 2012Negar Asdaghi MD FRCPCWhen not to treat..and what not to do

Mr PS81 year old, RHD retired family doctor

Presented with sudden onset of left sided weakness within 2.5hr of onset

PMHHTNDMDyslipidemiaCAD (stent 2001)Atrial fibrillation (not currently on OAC)Previous history of ICH (2001 AAICH (INR=8.9), 2008 spontaneous IVH)CRF


ASA 81 mg/dailyRamipril 5mg/dailyDiltiazem180 mg/dailySimvastatin 40 mg/dailyMetformin 500/BID

HPI Continued..Developed sudden onset of left sided weakness (F/A/L) associated with some confusion

No history of trauma, no seizure like activity

ExamSBP=165-170, HR= irregular, 100-120

Dense gaze preference to the right left HHA left sided neglectleft UMN facial weaknessLeft arm and leg 0/5Upgoing plantar response on the leftNIHSS=21

What to do..?2.5 hrs into a large acute Rt MCA strokePrior history of ICH No other contraindications12:30 a.m.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

Exclusion Criteria for tpa

422 patients were treated between 2006-201055% of cases were off-label

5594 IV-tpa treated patients, 34.3% off label use422 IV-tpa treated patients, 55% off label useOf 5594 consecutive patients, 1919 patients (343%) not fully adhered to the license. The most frequent deviations were: time-to-treatment >3 h (131%), use of intravenous antihypertensives (83%), age >80 years (73%), oral anticoagulation (42%), a previous stroke with concomitant diabetes (39%), and previous stroke 80over 13 yrs 1995-2008Helsinki insitute30Commonest reasons for of off-label use of tpa:Age>80Minor stroke (NIHSS3hrBP>185/110Anti-coagulation

The only only independent factor associated with poor outcome was age>80

31Canadian data on off label use of tPA

Treat fist ask questions later

Meta analysis of recent published studies on cerebral microbleeds and hemorrhage The overall prevalence of CMBs on pretreatmentMRI scans was 17.1%

Amongst patients with CMBs, 10/135 (7.4%) experienced a symptomatic ICH after thrombolysis, compared to 29/655 (4.4%) patients without CMBs; the pooled RR of ICH was 1.90 (95% CI 0.92 to 3.93; p=0.082)

(figure 1).33Ultimate Decision?

TreatmentIV tpa startedAngio suite staff on routePatient started moving his left arm within 20 min of infusionBy the time of puncture the only deficits were left HHA and some minor drift

NIHSS at 24 hours was 2No bleedingCourse in the hospital

Discharge Doing wellCrCl 30Decision to start Anti-coagulation?

Canadian best practice recommendations, 2012 OACSummaryOff label use of tpa is commonDifficult stroke scenarios occur frequently

You have to know the rules to break them