QUESTION: According to the most recent American Heart Association (AHA)/American Stroke Association (ASA) Stroke Council guidelines, which of the following patients is a candidate for the administration of tissue plasminogen activator (tPA)?
A. 61-year-old man with a left-sided facial droop and left-sided paresis that began 45 minutes prior to arrival, who has a history of cirrhosis, and his INR is 2.1
B. 67-year-old woman with decreased mentation and right-sided facial droop that began 60 minutes prior to arrival and has a blood glucose level of 45 mg/dL.
C. 69-year-old man with a history of an intracranial hemorrhage 5 years ago, who presents with 60 minutes of right-sided facial droop, aphasia, and left-sided paresis.
D. 75-year-old man diagnosed with a subdural hematoma 2 months ago after a fall and now presents with 30 minutes of aphasia and right-sided paresis
E. 75-year-old woman with dysarthria, right-sided motor and sensory deficits that began 2 hours prior to arrival, and has a blood pressure of 175/90 mm Hg
THE ANSWER IS E.
The current AHA/ASA guidelines for thrombolytics in stroke recommend treatment for patients who fit the following profile: Patients must have a measurable neurologic deficit that is not clearing spontaneously and is not minor and isolated. In those with severe deficits and a National Institutes of Health Stroke Scale (NIHSS) > 22, caution is advised because although there may be some benefit to therapy, there is a significant increase in the risk of intracranial hemorrhage. The patient in choice E does not have any contraindications for tPA therapy. [see epmonthly.com for table of contraindications]
An INR >1.7 (A) is a contraindication. Blood glucose less than 50 mg/dL (B) is a contraindication. Any history of an intracranial bleed (C) is a contraindication to tPA therapy. History of head trauma in the preceding 3 months (D) is a contraindication to tPA therapy.