The ambulance brought in an elderly male in his 70s into the ED. The son who accompanied him claimed that he was found lying on the floor with weakness of limbs and deviated mouth.
A quick evaluation had established a preliminary diagnosis of stroke. The patient was rushed to CT which did not reveal any hemorrhage. A detailed history was done again to assess the time of onset carefully.
Time was always essential for thrombolytic therapy. It had a within 3 hours limitation and later extended to 4.5 hours time frame for the drug infusion.
The checklist was a long one and some of tickboxs would require mercy from our lab.
The whole process became more challenging when the <60 minutes for door to drug standard was set.
However the most challenging part was determination of the onset. The patient came at 8am and dysarthria and partial aphasia was noted. He could nod while being asked. The son provided most of the history. He was found lying nearby his bed at 7+am by his wife and EMS was notified. So it looked like a wake up stroke and I proceeded to a CTA to see if the patient was available for a thrombectomy.
By 9am, the CTA came back with a M2 branch obstruction at the right MCA. The neurologist had come and finally the patient was able to say that he had woken up at 4am and was well then. It was about 9:05 then and we had initiated the thrombolytic therapy. The 60 minutes mark was broken however still within the 4.5 hours limit. The rest was routine, the patient was admitted to ICU and planned for a CT followed up tomorrow morning.
The next day when I hit the desk, K told me that the patient was drowsy in the middle of the night and a CT was done which was negative for any hemorrhage.
His consciousness did not improve though and an MRI was done later in the afternoon which revealed a striking result; left MVA infarction involving M1 branch. Well, thrombectomy was done later in the evening.
The patient remained comatose today and would unlikely recover from his condition.
He had underlying problem of atrial fibrillation but another stroke following thrombolytic therapy was definitely not seen often. I had seen patient who was not fit for thrombolytic therapy and later deteriorated. This patient was however the few one who developed another stroke over the contralateral side.
The guideline had changed and adding of the thrombectomy had made the decision more complicated than before. CTA, perfusion scan and KPI for the rtPA perfusion had made our life miserable since the publish of the new guideline.
