Whop pulls the tpa trigger?

[xaelia]

Anyone ever given TPA and then there is 100% improvement in symptoms?? I was wondering if someone who has resolution of symptoms after bolus and shortly after the TPA gtt started, do you stop the gtt then?

Doubtful you're going to find much in terms of evidence to guide such a decision.

The possibilities I see are:
1) You tPA'd a stroke mimic. Continuing the gtt only places them at additional risk.
2) You tPA'd some sort of cerebrovascular process in which the tissue at risk still had adequate blood supply to prevent complete infarction, whether some sort of stuttering/dynamic process of clot formation and resolution, or a stroke with excellent collateral supply. I would suspect the additional clot lysis from the remaining time on the gtt would improve their chances of retaining a persistently open vessel.

You'd probably have such a decision on an individualized basis, depending on (if present) results of a CTA, suspected infarct territory, prior psychiatric admissions ....

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[deleted547339]

On another note....

Anyone ever given TPA and then there is 100% improvement in symptoms?? I was wondering if someone who has resolution of symptoms after bolus and shortly after the TPA gtt started, do you stop the gtt then?

TPA doesn't work that fast. You either lysed a TIA or a mimic...either way, it doesn't need TPA. At that point, I think any harm has already been done, but I'd probably stop it.

 

[Apollyon]

TPA doesn't work that fast.

Are you sure about that? I mean, let's look at adverse effects. Ever seen someone start to bleed out of all holes? I have, and that happened quickly. (Well, relatively - as I could see it in the ED.) The plasminogen is cleaved to plasmin, and the plasmin causes fibrinolysis. The neurointensivists/neurosx/IR/vascular that do CVAs shoot the t-PA intra-arterially into the clot, and then balloon it. They're not waiting hours - it happens in minutes, right in front of them. I would venture that it does, indeed, work that quickly (although mine is a general statement - I am not saying one way or the other about IV t-PA for ischemic CVA).

 

[deleted109597]

I would venture that it does, indeed, work that quickly (although mine is a general statement - I am not saying one way or the other about IV t-PA for ischemic CVA).

Well, if you're basing that it works at all on the "positive" literature out there, there isn't any effect at 24 hours, so there likely isn't one before this. Effectiveness all determined at 30 days or greater. I too have seen people bleed from everywhere after tPA, but they weren't bleeding from where the clots were. Also, they still died of their clot, so it clearly didn't treat that.

 

[deleted547339]

Are you sure about that? I mean, let's look at adverse effects. Ever seen someone start to bleed out of all holes? I have, and that happened quickly. (Well, relatively - as I could see it in the ED.) The plasminogen is cleaved to plasmin, and the plasmin causes fibrinolysis. The neurointensivists/neurosx/IR/vascular that do CVAs shoot the t-PA intra-arterially into the clot, and then balloon it. They're not waiting hours - it happens in minutes, right in front of them. I would venture that it does, indeed, work that quickly (although mine is a general statement - I am not saying one way or the other about IV t-PA for ischemic CVA).

All the literature says no difference at short intervals. I've heard and seen people who quickly get better after TPA, but the literature just doesn't bore out that it's from the TPA.

Also, surprised your shop is doing directed thrombolysis with mechanical intervention. I may be wrong, but I thought the most recent NEJM article on clot retrievement devices says they should only be used for trials.

 

[MSmentor018]

Also, surprised your shop is doing directed thrombolysis with mechanical intervention. I may be wrong, but I thought the most recent NEJM article on clot retrievement devices says they should only be used for trials.

I've seen pts miraculously get better after tpa administration but that's few and far between. heck maybe it was a TIA that resolved, a pseudosz that stopped or maybe it worked. who knows.

i work at in academics and community, both shops have identical algorhythms. Tpa given, if no resolution of symptoms (depending on the perfusion scan/location of clot) then interventional

 

[TooMuchResearch]

All the literature says no difference at short intervals. I've heard and seen people who quickly get better after TPA, but the literature just doesn't bore out that it's from the TPA.

Also, surprised your shop is doing directed thrombolysis with mechanical intervention. I may be wrong, but I thought the most recent NEJM article on clot retrievement devices says they should only be used for trials.

Yeah, but the authors of that paper still probably do them. One of them was on EM:RAP in 5/2013 saying that the procedure works, regardless of the results and conclusions of his own study. It bills well, and in the end, billing for services is more important than treating patients.

 

[Apollyon]

All the literature says no difference at short intervals. I've heard and seen people who quickly get better after TPA, but the literature just doesn't bore out that it's from the TPA.

Also, surprised your shop is doing directed thrombolysis with mechanical intervention. I may be wrong, but I thought the most recent NEJM article on clot retrievement devices says they should only be used for trials.

My shop isn't doing it. I was talking about the basic science of plasmin on the molecular level - not about the politics of antithrombotic therapy.

 

[southerndoc]

I've seen pts miraculously get better after tpa administration but that's few and far between. heck maybe it was a TIA that resolved, a pseudosz that stopped or maybe it worked. who knows.

i work at in academics and community, both shops have identical algorhythms. Tpa given, if no resolution of symptoms (depending on the perfusion scan/location of clot) then interventional

A TIA doesn't show as a stroke on MRI. All patie to given TPA should have an MRI within 24 hours. Even those that completely recover will have evidence of a mild stroke on MRI.

 

[MSmentor018]

correct. you can get fooled by the ct but not the MRI. they are working on a new scoring system. ABCD3-I to account for the accuracy of MRI

http://stroke.ahajournals.org/content/45/2/418.full