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CASE REPORT ■

THROMBOLYTIC THERAPY IN ACUTE STROKE


Yen-Wei Hsu1, Chuan-Chuan Liu2, I-Fang Liu3, Wai-Mau Choi3*
1
Department of Neurology, Mackay Memorial Hospital, Hsinchu Branch, Hsinchu, 2Department of Laboratory,
Mackay Memorial Hospital, Taipei, and 3Department of Emergency Medicine, Mackay Memorial Hospital,
Hsinchu Branch, Hsinchu, Taiwan.

SUMMARY
Stroke as a cerebral dysfunction is strongly related to obstruction of cerebral perfusion. Thrombolytic agents
have dramatic medical effects on reperfusion after cerebral infarction. Thus, early diagnosis and proper use of
thrombolytic agents have become key events for successful treatment of stroke. We present a 63-year-old male
patient who had sudden onset of left-sided weakness and slurred speech. After a prompt diagnosis and throm-
bolytic treatment, the patient was quickly restored from his neurologic defects and discharged without disability.
Relevant literature is reviewed and discussed in the report. [International Journal of Gerontology 2008; 2(3):
140–142]

Key Words: stroke, thrombolytic therapy

Introduction Case Report

Stroke is a state of cerebral dysfunction that is usually A generally healthy retired 63-year-old male of average
caused by obstruction of perfusion in cerebral vessels. body weight presented at our emergency department
Stroke can be divided into three patterns: embolic, (ED) with left-side hemiparesis and dysarthria. He was
thrombotic, and lacunar. It typically affects people with a retired bicycle salesman, who, except for his smoking
a heart disease or elderly people with multiple med- (one pack per day for over 30 years) and hypertension,
ical problems. Thrombolytic therapy has been proven generally maintained healthy daily activities and lived
to exhibit strong potency for the treatment of stroke. independently. At 14:55 on the day of the stroke, he was
Morbidity and mortality are directly related to the dura- giving his neighbor a haircut. All of a sudden, his neigh-
tion and intensity of the stroke and the timing of throm- bor realized that the patient was lying on his back. Soon,
bolytic agent administration. The National Institutes the patient found it difficult to talk clearly and move
of Health Stroke Scale (NIHSS) is a good tool for evalu- his left-side limbs. He was immediately sent to our ED.
ation of stroke severity. Early diagnosis and proper treat- The patient arrived at our ED at 15:29. The initial
ment are crucial for the patient’s survival and level of conscious status was clear, Glasgow Coma Scale was
disability. We present a 63-year-old male patient who E4M5V6, and the tympanic temperature was 36.2°C.
had suffered a stroke. After emergency treatment with His initial vital signs were: heart rate, 82 beats per
a thrombolytic agent followed by supportive care, he minute; respiratory rate, 18 breaths per minute; blood
recovered and was discharged without any significant pressure, 193/91 mmHg. The initial serum biochem-
sequelae. istry data were: hemoglobin, 15.9 g/dL; hematocrit,
44%; white blood cell count, 8.10 × 103/μL; platelets,
184 × 103/μL; serum glucose (ante cibum), 113 mg/dL;
*Correspondence to: Dr Wai-Mau Choi, Mackay aspartate aminotransferase, 27 U/L; serum urea
Memorial Hospital, Hsinchu Branch, 690, Section
nitrogen, 19 mg/dL; creatinine, 1.2 mg/dL; potassium,
2, Guangfu Road, Hsinchu, Taiwan.
E-mail: L200@ms7.mmh.org.tw 3.5 mEq/L; sodium, 137 mEq/L. Chest X-rays showed
Accepted: June 12, 2008 no significantly abnormal findings. Electrocardiogram

140 International Journal of Gerontology | September 2008 | Vol 2 | No 3


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■ Thrombolytic Therapy in Stroke ■

showed normal sinus rhythm. Brain computed tomog- Discussion


raphy (CT) without enhancement showed no obviously
abnormal findings. The left-side limbs were pro- People with stroke may experience one-side limb
foundly weak (muscle power gradient [MP], 1). Obvious weakness, slurred speech and other variable focal
slurred speech was present, but no sensation defects neurologic defects. These may cause multiple medical
were found. A review of the patient’s history revealed and economical problems. Embolic type stroke largely
no antiplatelet or anticoagulation medications. The comes from atrial fibrillation1, the thrombotic type
initial NIHSS score was 11. After a full explanation of arises from vessel atheroma2,3, and the lacunar type
the risks, the patient agreed to undergo recombinant arises in a distal vessel under a complex segmental
tissue plasminogen activator (rt-PA) treatment. At arterial disorganization called lipohyalinosis4.
16:55, the first 1/10 dosage of rt-PA was given by an In the case of this 63-year-old patient, cigarette
intravenous (IV) push, followed by administration of the smoking and hypertension may be the major risk
remaining 9/10 dosage of rt-PA by an IV drip within factors that contributed to his stroke. Both factors can
1 hour. cause vessel atherosclerosis and represent the leading
• At 17:05, the patient could raise his left leg (anti- cause of ischemic stroke.
gravity), and the MP of the leg was 3. According to the patient’s history and neurology
• At 17:07, the patient could also elevate his left arm examination, stroke was our preliminary diagnosis.
(antigravity), and the MP of the arm was 3. How- Because the patient arrived at the ED very quickly with
ever, the systolic blood pressure was elevated to an exact onset time and without any hemorrhage or
200 mmHg at this time. cerebral defects on brain CT images, thrombolytic ther-
• At 17:40, there was more improvement of the left apy5–7 was the most suitable medical treatment. Con-
limb paresis, and the MP was 4–4+. The patient firming the exact onset time is an important point for
could move freely with a little difficulty. thrombolytic therapy. The time of onset has to be con-
• At 17:55, the rt-PA dosage was complete. The MP firmed by a witness, and any challenged time cannot be
remained at 4–4+ in the left arm and leg. trusted. This information is all-important, because
• At 19:50 and 2 hours after completion of the rt-PA thrombolytic therapy within 3 hours has the greatest
treatment, the NIHSS improved to 4. benefit. Beyond this time limit, the advantages quickly
• At 24 hours after completion of the rt-PA treatment, decline and hemorrhage side effects occur instead.
the NIHSS improved to 2. Under this concept, confirmation of the onset time
After these emergency management procedures in should be the foundation of thrombolytic therapy. rt-PA,
our ED, the patient was admitted to an ordinary ward the key medication of thrombolytic therapy, has been
under the diagnosis of stroke for further treatment and proven to be effective for treating ischemic stroke.
observation. However, it also has a remarkable side effect of massive
During hospitalization, the patient received a stroke bleeding8. The application of this medication should be
workup study. His carotid duplex showed a high resistant strictly according to the guidelines designed for throm-
flow profile in the bilateral common carotid arteries bolytic therapy. In Taiwan, we follow the guidelines
and right vertebral artery. Heart echography showed published by the Taiwan Stroke Society9. These guide-
mild pulmonary hypertension. Follow-up brain CT lines provide a good and safe framework for launching
without contrast media showed a low-density area in thrombolytic therapy as long as they are strictly followed.
the right basal ganglion and corona radiata. Some days Brain CT images provide important information for
later, the patient developed a fever. Urinalysis showed performing thrombolytic therapy. First, brain CT can eas-
a mild infection, but it soon subsided after treatment. ily identify ischemic stroke from hemorrhagic stroke.
The highly elevated blood pressure was also decreased Second, it can help us to detect early cerebral infarc-
and controlled by medication. tion10, which may easily be confused in normal images.
After admission for 5 days, the patient was dis- Blood pressure control11 remains an essential issue
charged and returned to his normal daily life without once thrombolytic therapy has been launched. In the
any significant sequelae. He maintained regular out- first hour, blood pressure should be monitored every
patient visits. At the latest visit, he appeared to be a 15 minutes during infusion, followed by every 30 min-
healthy and independent individual. utes for the next 2 hours and hourly for another 5 hours.

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■ Y.W. Hsu et al ■

It is important not only to monitor blood pressure fre- by two-dimensional echocardiography. Stroke 1983; 15:
quently, but also to carry out hourly neurology obser- 541–5.
vations. Neurology observations need to be carefully 2. Duguid JB. The Dynamics of Atherosclerosis. Aberdeen:
monitored, because any sudden elevation in blood Aberdeen University Press, 1976.
3. Ebrahim S, Harwood R. Stroke: Epidemiology, Evidence
pressure or change in the neurology conditions could
and Clinical Practice. Oxford: Oxford University Press,
indicate a massive intracranial hemorrhage, which may 1999.
require brain CT for clarification and may lead to con- 4. Fisher CM. Lacunar infarcts: a review. Cerebrovasc Dis
sideration of a further operation to relieve the crisis. 1991; 1: 311–20.
The NIHSS, which was developed by the National 5. Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A,
Institutes of Health to evaluate stroke severity in Meier D, et al. Randomised double-blind placebo-
patients, has become a very good evaluation tool for controlled trial of thrombolytic therapy with intravenous
stroke patients. According to its indications, stroke alteplase in acute ischaemic stroke (ECASS II). Second
patients with scores under 6 do not need to undergo European-Australasian Acute Stroke Study Investigators.
Lancet 1998; 352: 1245–51.
thrombolytic therapy, because their injuries are very
6. The National Institute of Neurological Disorders and
mild. Furthermore, stroke patients with scores of more
Stroke rt-PA Stroke Study Group. Tissue plasminogen acti-
than 25 cannot undergo the therapy, because their vator for acute ischemic stroke. N Engl J Med 1995; 333:
injuries are too severe. Therefore, the NIHSS not only 1581–7.
evaluates stroke severity but can also be considered as a 7. Adams HP Jr, Brott TG, Furlan AJ, Gomez CR, Grotta J,
prognostic index. In our case, it was obvious during the Helgason CM, et al. Guidelines for thrombolytic therapy
thrombolytic therapy that his NIHSS was improving as for acute stroke: a supplement to the guidelines for the
long as his clinical condition continued to improve. management of patients with acute ischemic stroke: a
From this case and the related literature, we con- statement for healthcare professionals from a Special
Writing Group of the Stroke Council, American Heart
clude that stroke is the third leading cause of death of
Association. Circulation 1996; 94: 1167–74.
elderly people and the most severe cause of disability12.
8. The NINDS t-PA Stroke Study Group. Intracerebral hemor-
Proper treatment of stroke should be the strategy, rhage after intravenous t-PA therapy for ischemic stroke.
because it could reduce the burden of stroke and Stroke 1997; 28: 2109–18.
improve public health. Prevention of stroke is not only 9. Taiwan Stroke Society Consensus Group on Guidelines
a medical problem but also an economic issue. for rt-PA Use. [Guidelines for the intravenous throm-
Thrombolytic therapy has shown its importance in the bolytic therapy in acute ischemic stroke.] Nao Zhong
treatment of acute stroke. Confirmation of the exact Feng Hui Xun 2003; 10: 4–11. [In Chinese]
onset time, normal initial brain CT images, qualified 10. von Kummer R, Allen KL, Holle R, Bozzao L, Bastianello S,
NIHSS evaluation, and proper rt-PA usage can lead to Manelfe C, et al. Acute stroke: usefulness of early CT find-
ings before thrombolytic therapy. Radiology 1997; 205:
successful thrombolytic therapy.
327–33.
11. Brott T, Lu M, Kothari R, Fagan SC, Frankel M, Grotta JC,
et al. Hypertension and its treatment in the NINDS rt-PA
References Stroke Trial. Stroke 1998; 29: 1504–9.
12. Murray CJL, Lopez AD. Mortality by cause for eight
1. Nishide M, Irino T, Gotoh M, Naka M, Tsuji K. Cardiac regions of the world: Global Burden of Disease Study.
abnormalities in ischemic cerebrovascular disease studied Lancet 1997; 394: 1269–76.

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