tPA used in stroke

1. Case Presentation

2. History
• 51years male presented to ER with Complaints
of weakness of Right side of body which was
sudden in onset associated with Deviation of
mouth to left side and Aphasia 1 and half hour
prior to entry in hospital.
• No H/O LOC, Abnormal body movement ,
vomiting .
• He was diagnosed case of HTN since 4 years
and was under medication (Amlod 5mg)

3. Examination
• GC : Fair
• PICCLED :Nil
• M.P: 5/5 in left upper and lower limb
• 3/5 in Right upper and lower limb
• Grasping : Decreased in right than left
• Sensory: Decreased in Right side
• Jerks: Normal

4. Continue
• CT Head (Computed Tomography) was
performed to rule out Hemorrahagic/
Ischemic Stroke.However the ct head turned
to be normal.So, MRI –DWI was done which
also turned to be normal.
• Since , patient presented with in window
period (4.5 hours) of rTPA infusion.All the
contraindications for rTPA like …………was
ruled out.

5. Continue
• Patient was admitted in ICU.
• Two wide bored cannula was opened in both
hand.one for rTPA infusion and other for IVF.
• PT/INR was send which came to be normal i.e, 1.0
, Bleeding time and clotting time (1.30 minute
and 7 minute) respectively.
• Patient weight was calculated .
• rTPAat the dose of 0.9mg/kg with 10%of bolus
(loading dose )was administrated and remaining
dose was infused slowly within 1 hour.

6. continue
• Within the infusion of rTPA , patient showed
improvement in his symptoms.His aphasia
resolved and the motor power also improved.
• Also he didn’t show any symptom of the
active bleeding following the rTPA infusion.
• He was kept in ICU for 24 hour for observation
and then shifted to ward.

7. continue
• All his Cardiac Enzymes, Lipid Profile , HbA1C
was send which was normal.
• ECHO Heart shows Mild Mitral Stenosis (MVA
approximately 1.6cm sq),Trivial to mild MR
with LVEF 60 %.
• Cardiac consultation was done during his
hospital stay.

8. continue
• He was discharge on the 3rd day of admission
with power 5/5 in all his 4 limbs and able to
speak.
• He was discharged with Oral medication i.e,
Ecospirin 150mg and Statin 20mg .
• Patient had RHD with mild MS which makes
him vulnerable for new strokes in future.
• He was planned for warfarin in coming days.
• He was in regular follow up since 8 months.

9. continue
• He was started with Warfarin ……..mg after
………

10. CT Scan Head

11. MRI-DWI Head

12. Second Case
• 87 Year male presented with Complaints of
Sudden onset of weakness of left side of body
3hrs prior to entry to hospital associated with
slurring of speech.
• It was not associated with LOC,Abnormal body
movement, vomiting.
• He was known case of HTN, DCM and AF
(under Tab.Ecospirin) but document was not
available.

13. Examination
• GC : Fair
• GCS :15/15
• Resp: B/L NVBS
• Chest: Decreased air entry on left side
• M.P : Right upper and lower limb- 5/5
• Left upper - 3/4 and lower -4/5
• Grasping : Decreased in left side

14. continue
• He was presented to ER within Window period i.e, 3hrs
from onset of the symptoms.
• Was admitted in ICU after CT Head was done.
• His CT Head showed Hypodense area in Right MCA
territory .
• As he was under Ecospirin , Bleeding Profile and PT/INR
(1.21) was checked which came to be normal .
• Counselled for rTPA and 65mg of rTPA was
administrated i.e, 0.9mg/kg body weight after
explaning all complications like Bleed from different
site of pricking point and Hemorrhage in Brain.

15. continue
• He was presented to ER within Window period i.e, 3hrs
from onset of the symptoms.
• Was admitted in ICU after CT Head was done.
• His CT Head showed Hypodense area in Right MCA
territory .
• As he was under Ecospirin , Bleeding Profile and PT/INR
(1.21) was checked which came to be normal .
• Counselled for rTPA and 65mg of rTPA was
administrated i.e, 0.9mg/kg body weight after
explaning all complications like Bleed from different
site of pricking point and Hemorrhage in Brain.

16. continue
• After 10% of loading dose ,Maintainance dose
was infused slowly within 1 hour.
• Immediately after administration of rTPA his
symptom has improved i.e, Speech.He was
able to Speak Clearly.
• Due to multiple prick at left hand by other
center he had swelling over the pricking point
and bleeding from the gums which was
managed by ice compression.

17. Continue
• He was then shifted to Ward after 24hrs
observation in ICU.
• He was started with Triple –H therapy , Anti-
Platelets, Statins, IVF and other supportive
measures after 24 hrs of rTPA infusion.
• Carotid Doppler revealed diffuse
artherosclerosis on both side causing 25%
stenosis of right distal CCA.

18. • He was discharged on the 4th day of admission
.At the time of discharge his power was 5/5 in
left upper and lower limbs and can speak
properly.
• Advised for regular follow up.
• ………..

19. CT Head