General

CT identifies patients in stroke treatment window

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25 Nov 2016 - General
 

The link to the article: http://www.nature.com/nrneurol/journal/vaop/ncurrent/full/nrneurol.2016.184.html

*For some reason I cannot share it through the share link button*

Timing is very crucial to the administration of intravenous thrombolysis. One caveat to following the standard guideline of giving intravenous thrombolysis within the 4.5 hr period is the lack of an objective measure that detects onset. At present CT scans and MRIs are limited to identifying if there is vascular compromise, the location of such, and if there is a compressive effect to the surrounding neural tissue. I think that if this form of treatment will be available, the it will help determine patients who are indeed eligible for intravenous thrombolysis. Moreso, another multicenter study can be done utilizing this technology to improve current guidelines, since these guidelines are also based on nonobjective parameters when it comes to determining stroke ictus. Do you follow a similar guideline in your local practice? 

Thanks for sharing the experience. The door to needle time is very importance in thrombolysis of ischaemic stroke. I would say the standard guideline of thrombolysis within 4.5 hours will be the standards guideline. Stroke is a clinical diagnosis, CT-brain is done to rule out the possibility of haemorrhagic stroke. In some centre with thrombectomy service by neurology intervention radiologist, CT-Cerebral angiogram will be done together, in the same time with the standard CT-brain, in order to...
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Marinelle Castro The same protocol is also done in our institution. If the history and physical examination suggest a possible upper motor neuron lesion, the internal medicine service (neurology is incorporated with internal medicine in our institution) will always request for a plain cranial CT scan to rule out the possibility of hemorrhage. If the CT scan does not show hemorrhage, the problem now lies in determ...
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Mark Edmon Tan In our institution, we also rely on history and physical exam to get the location of the stroke. However, we always perform a plain cranial CT on all patients who are potentially eligible for intravenous thrombolysis because of the possibility of a hemorrhagic stroke. Unfortunately, there is accurate way to determine if it is a hemorrhagic infarct or there is already hemorrhagic conversion. Usuall...
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Marinelle Castro It becomes really problematic with thrombotic infarcts, most of which occur during sleep. It would be extremely unreliable to base giving of rTPA on clinical history. Right now there is no clear cut ancillary the can determine the onset of focal neurologic deficit other than history taking. CT scan cannot be reliable as it infarcts can take up to 48 to 72 hours before it is seen in the films. In ...
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Habiba Twakkol Thank you for giving your valuable insights on the topic. I have seen the devastating complication of intravenous thrombolysis. Some of the patients who developed hemorrhagic infarcts are immediately referred to our service for surgical evaluation. I am uncertain if moving around has anything to do with the development of hemorrhagic infarcts, but based on the pathophysiology of its development as...
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In my experience, there is a problem with determining reliability of stroke ictus, which one of the determinants if the patient is a good candidate for intravenous thrombolysis. Most of the time, relatives are an unreliable source because they are not with the patient when symptoms started. Sometimes they would claim that its 3 hours or so, but they are not sure. Would you know how these patients are managed in your institution ...
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Marinelle Castro i'm a pharmacist and this is not my work field but I think that there are certain symptoms you see which lead you to take this step even if the examination is not complete.
For thrombolytic therapy to be effective in treating stroke or heart attack, prompt medical attention is very important. The drugs must be given within a few hours of the beginning of a stroke or heart attack. This ty...
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Marinelle Castro I agree that timing is very crucial and we are lucky that the window was adjusted to within 4.5 hours from the previous 3 hours post-ictus. Immediate thrombolytic agents may help in reducing focal neurologic deficits and salvage the ischemic penumbra. In our institution, the same guideline is also used. CT scan is the imaging of choice because it is more sensitive to hemorrhagic infarcts that are...
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