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

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■ Thrombolytic Therapy in Stroke
showed normal sinus rhythm. Brain computed tomog-
raphy (CT) without enhancement showed no obviously
abnormal findings. The left-side limbs were pro-
foundly weak (muscle power gradient [MP], 1). Obvious
slurred speech was present, but no sensation defects
were found. A review of the patient’s history revealed
no antiplatelet or anticoagulation medications. The
initial NIHSS score was 11. After a full explanation of
the risks, the patient agreed to undergo recombinant
tissue plasminogen activator (rt-PA) treatment. At
16:55, the first 1/10 dosage of rt-PA was given by an
intravenous (IV) push, followed by administration of the
remaining 9/10 dosage of rt-PA by an IV drip within
1 hour.
• At 17:05, the patient could raise his left leg (anti-
gravity), and the MP of the leg was 3.
• At 17:07, the patient could also elevate his left arm
(antigravity), and the MP of the arm was 3. How-
ever, the systolic blood pressure was elevated to
200 mmHg at this time.
• At 17:40, there was more improvement of the left
limb paresis, and the MP was 4–4+. The patient
could move freely with a little difficulty.
• At 17:55, the rt-PA dosage was complete. The MP
remained at 4–4+ in the left arm and leg.
• At 19:50 and 2 hours after completion of the rt-PA
treatment, the NIHSS improved to 4.
• At 24 hours after completion of the rt-PA treatment,
the NIHSS improved to 2.
After these emergency management procedures in
our ED, the patient was admitted to an ordinary ward
under the diagnosis of stroke for further treatment and
observation.
During hospitalization, the patient received a stroke
workup study. His carotid duplex showed a high resistant
flow profile in the bilateral common carotid arteries
and right vertebral artery. Heart echography showed
mild pulmonary hypertension. Follow-up brain CT
without contrast media showed a low-density area in
the right basal ganglion and corona radiata. Some days
later, the patient developed a fever. Urinalysis showed
a mild infection, but it soon subsided after treatment.
The highly elevated blood pressure was also decreased
and controlled by medication.
After admission for 5 days, the patient was dis-
charged and returned to his normal daily life without
any significant sequelae. He maintained regular out-
patient visits. At the latest visit, he appeared to be a
healthy and independent individual.
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■
Discussion
People with stroke may experience one-side limb
weakness, slurred speech and other variable focal
neurologic defects. These may cause multiple medical
and economical problems. Embolic type stroke largely
comes from atrial fibrillation1, the thrombotic type
arises from vessel atheroma2,3, and the lacunar type
arises in a distal vessel under a complex segmental
arterial disorganization called lipohyalinosis4.
In the case of this 63-year-old patient, cigarette
smoking and hypertension may be the major risk
factors that contributed to his stroke. Both factors can
cause vessel atherosclerosis and represent the leading
cause of ischemic stroke.
According to the patient’s history and neurology
examination, stroke was our preliminary diagnosis.
Because the patient arrived at the ED very quickly with
an exact onset time and without any hemorrhage or
cerebral defects on brain CT images, thrombolytic ther-
apy5–7 was the most suitable medical treatment. Con-
firming the exact onset time is an important point for
thrombolytic therapy. The time of onset has to be con-
firmed by a witness, and any challenged time cannot be
trusted. This information is all-important, because
thrombolytic therapy within 3 hours has the greatest
benefit. Beyond this time limit, the advantages quickly
decline and hemorrhage side effects occur instead.
Under this concept, confirmation of the onset time
should be the foundation of thrombolytic therapy. rt-PA,
the key medication of thrombolytic therapy, has been
proven to be effective for treating ischemic stroke.
However, it also has a remarkable side effect of massive
bleeding8. The application of this medication should be
strictly according to the guidelines designed for throm-
bolytic therapy. In Taiwan, we follow the guidelines
published by the Taiwan Stroke Society9. These guide-
lines provide a good and safe framework for launching
thrombolytic therapy as long as they are strictly followed.
Brain CT images provide important information for
performing thrombolytic therapy. First, brain CT can eas-
ily identify ischemic stroke from hemorrhagic stroke.
Second, it can help us to detect early cerebral infarc-
tion10, which may easily be confused in normal images.
Blood pressure control11 remains an essential issue
once thrombolytic therapy has been launched. In the
first hour, blood pressure should be monitored every
15 minutes during infusion, followed by every 30 min-
utes for the next 2 hours and hourly for another 5 hours.
141
■ Y.W. Hsu et al
It is important not only to monitor blood pressure fre-
quently, but also to carry out hourly neurology obser-
vations. Neurology observations need to be carefully
monitored, because any sudden elevation in blood
pressure or change in the neurology conditions could
indicate a massive intracranial hemorrhage, which may
require brain CT for clarification and may lead to con-
sideration of a further operation to relieve the crisis.
The NIHSS, which was developed by the National
Institutes of Health to evaluate stroke severity in
patients, has become a very good evaluation tool for
stroke patients. According to its indications, stroke
patients with scores under 6 do not need to undergo
thrombolytic therapy, because their injuries are very
mild. Furthermore, stroke patients with scores of more
than 25 cannot undergo the therapy, because their
injuries are too severe. Therefore, the NIHSS not only
evaluates stroke severity but can also be considered as a
prognostic index. In our case, it was obvious during the
thrombolytic therapy that his NIHSS was improving as
long as his clinical condition continued to improve.
From this case and the related literature, we con-
clude that stroke is the third leading cause of death of
elderly people and the most severe cause of disability12.
Proper treatment of stroke should be the strategy,
because it could reduce the burden of stroke and
improve public health. Prevention of stroke is not only
a medical problem but also an economic issue.
Thrombolytic therapy has shown its importance in the
treatment of acute stroke. Confirmation of the exact
onset time, normal initial brain CT images, qualified
NIHSS evaluation, and proper rt-PA usage can lead to
successful thrombolytic therapy.
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■
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