Very few decisions in emergency medicine are as challenging as whether or not to give a “thrombolytic” to someone suffering a stroke. This hasn’t changed at all for me since residency, though the window of opportunity has stretched a bit beyond 3 hours now. There are a few more interventions available today by interventional neurologists as well.

Stroke centers are popping up with “time is brain” as their mantra. However, in reality, patients who arrive shortly after their symptoms appear face one of the toughest choices they may ever make:

Behind door one – “You probably won’t get worse. You may stay this way forever. Maybe you will slowly get better. Or perhaps you’ll be better quickly and we’ll call you a TIA.”

Behind door two – “You may get better quick. You may get worse quick. Or you may die.”

Red Flags:

• Difficulty speaking
• One sided weakness
• Unconscious
• Past strokes
• Hypertension
• Atrial fibrillation
• Cancer or other problems causing clots
• Pregnant
• Elderly
• Smoker
• Relatives with past strokes

Happy Words

• *not really “happy,” but rather anything that may suggest another cause.
• Intoxication
• Diabetes
• Psychiatric illness
• Isolated sensory loss
• Fever
• Isolated facial paralysis (Bell’s palsy)
• “I ran a marathon, and I’ve been hydrating with water, and I take diuretics.” (Hypokalemic paralysis)
• “I sat with my legs crossed too long and now I can’t feel them.”

Patients who arrive less than 3-4.5 hours from the start time of their slurred speech, weakness, numbness, altered mentation, etc. are typically whisked to a CT scanner. We look to see whether bleeding in the brain is evident or not. This defines “hemorrhagic” vs. “ischemic” stroke. The former are relatively boring, because generally there is very little to offer other than admission and monitoring. (Giving these folks a thrombolytic is a very bad idea.)

On the other hand, patients suffering ischemic strokes are the folks who face the decision of a lifetime. While many will improve with thrombolytics, some fraction may convert to hemorrhagic strokes, and some fraction of them will die. Personally, I’ve seen patients improve rapidly or remain unchanged. I’ve been lucky. I also know a neurologist who refuses entirely to offer thrombolytics, because of witnessing patients who have died.

For doctors, it boils down to comfort with sins of commission vs. omission. Which is worse, to be the person who gave a medicine that killed someone, or to be the person who didn’t give a medicine that could save someone? It’s hard to know, but that’s why I type. Patients and families need to know this dynamic exists, because ultimately it is their choice.

My last ER shift was neurologically heavy: One stroke, followed by a large intracranial bleed, followed by a child with a seizure, fever and possible tumor on CT. My stroke patient got me typing today, and this is how I frame her options: “Would you be comfortable living the rest of your life with your current weakness and slurred speech? If the answer is no, then are you comfortable taking the risk that our medicine could kill you?” My patient chose door 1. She was already improving, probably thanks to the aspirin she took at home before heading in.

If you want to dig dipper read TPA Contraindications for Ischemic Stroke.

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