Anyone else's Neurology dept a little too loose with the tPA?

[Amazingmuzmo]

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I don't really think that's aphasia so much as the recent immigrant not knowing that the english word for the picture you're showing him is "hammock"...

 

[southerndoc]

Hilarious. 🙂

 

[Arcan57]

tPA is a safe and effective drug with essentially no side effects of any importance. It should be offered to everyone who doesn’t have an intracranial hemorrhage on CT scan regardless of symptoms.

 

[deuist]

tPA is a safe and effective drug with essentially no side effects of any importance. It should be offered to everyone who doesn’t have an intracranial hemorrhage on CT scan regardless of symptoms.

I found the Genetech schill.

 

[alphaholic06]

tPA is a safe and effective drug with essentially no side effects of any importance. It should be offered to everyone who doesn’t have an intracranial hemorrhage on CT scan regardless of symptoms.

Sounds my stroke/sepsis coordinator talking.

Sent from my Pixel using SDN mobile

 

[TooMuchResearch]

You haven't lived until you've given alteplase to a drunk 90 year old who had some word finding difficulty at lunch that is no longer present.

 

[Psai]

You haven't lived until you've given alteplase to a drunk 90 year old who had some word finding difficulty at lunch that is no longer present.

How do you know that they wouldn't have recovered if you left them alone?

 

[Rendar5]

tPA is a safe and effective drug with essentially no side effects of any importance. It should be offered to everyone who doesn’t have an intracranial hemorrhage on CT scan regardless of symptoms.

Agreed. Gave it to a patient with a cold who had a negative head CT. I checked on him a week later and he made a full recovery.

 

[Zebra Hunter]

Anyone read the recent NEJM article on tPA for wake-up strokes? Pts had MRI to confirm recency of stroke, or more accurately ischemia amenable to intervention (wish they had used CT perfusion scan, as well, since this is the more common perfusion imaging across the country). Primary outcome of good neuro outcome (mRS 0-1) was 53% vs 42% (tPA vs placebo). Death was 4.2% vs 1.2% (not technically statistically significant). ICH 2% vs 0.4% (again not significant).

I think this definitively demonstrates improved neurological outcomes w/ tPA when strict inclusion and exclusion criteria are adhered to. It also less definitively demonstrates what we already know, that more people die w/ tPA. There doesn’t appear to be any statistical gymnastics. The only issue is that they cut the trial short by 300 patients.

NEJM - Error

 

[WilcoWorld]

Anyone read the recent NEJM article on tPA for wake-up strokes? Pts had MRI to confirm recency of stroke, or more accurately ischemia amenable to intervention (wish they had used CT perfusion scan, as well, since this is the more common perfusion imaging across the country). Primary outcome of good neuro outcome (mRS 0-1) was 53% vs 42% (tPA vs placebo). Death was 4.2% vs 1.2% (not technically statistically significant). ICH 2% vs 0.4% (again not significant).

I think this definitively demonstrates improved neurological outcomes w/ tPA when strict inclusion and exclusion criteria are adhered to. It also less definitively demonstrates what we already know, that more people die w/ tPA. There doesn’t appear to be any statistical gymnastics. The only issue is that they cut the trial short by 300 patients.

NEJM - Error

Yeah, but cutting a trial short and then blowing off a three-fold mortality difference as "non-significant" is awfully suspicious.

 

[theseeker4]

Yeah, but cutting a trial short and then blowing off a three-fold mortality difference as "non-significant" is awfully suspicious.

Hey, you got to stop these trials before the numbers force you to say "statistically significant increased risk of mortality."

 

[Arcan57]

Hey, you got to stop these trials before the numbers force you to say "statistically significant increased risk of mortality."

They wanted 800, they got roughly 500. The “patients planned for but not enrolled in the trial” group was bigger than either the intervention or placebo group.

Honestly, as we treat smaller and smaller deficits, tPA is going to continue to look better and better. As a miracle worker in severe strokes it clearly doesn’t work. As a mostly harmless adjunct to convert minor strokes, unresolved TIAs, and stroke mimics into lucrative short stay ICU admits it works well.

 

[TooMuchResearch]

They wanted 800, they got roughly 500. The “patients planned for but not enrolled in the trial” group was bigger than either the intervention or placebo group.

Honestly, as we treat smaller and smaller deficits, tPA is going to continue to look better and better. As a miracle worker in severe strokes it clearly doesn’t work. As a mostly harmless adjunct to convert minor strokes, unresolved TIAs, and stroke mimics into lucrative short stay ICU admits it works well.

It's the best treatment for TIA.

 

[TooMuchResearch]

It also helps to change the definition of stroke. No symptoms but a teeny tiny little area of MRI? Stroke, treated with tPA.

 

[WilcoWorld]

Hey, you got to stop these trials before the numbers force you to say "statistically significant increased risk of mortality."

I should acknowledge that sometimes mortality is the most desirable, available outcome.

 

[NITRAS]

I HAVE seen the ER doc try and give tPa to a drunk. It was 2 am. That was a fun argument with the ER staff as a resident.

The pendulum will swing back and forth. Now we are CTAing everyone looking for those 2% of patients neurosurgery gets to try and work their magic.

 

[GeneralVeers]

We were going to give it to a patient with signs of left MCA stroke. He was young, but strangely kept refusing it. Turns out he had used cocaine just PTA, and as soon as it wore off, his neuro deficits disappeared.

 

[WilcoWorld]

We were going to give it to a patient with signs of left MCA stroke. He was young, but strangely kept refusing it. Turns out he had used cocaine just PTA, and as soon as it wore off, his neuro deficits disappeared.

Did you get an angiogram?

 

[GeneralVeers]

Did you get an angiogram?

Yes we did. I didn't let his TPA refusal slow down the workup. It was negative of course.

 

[deleted547339]

Everyone’s neuro Department is a lot too loose with tPA.