tPA in recurrent TIA

[Brooklyn523]

I have a question regarding tPA administration in a patient admitted with recurrent TIA's.

Hypothetical scenario:

65 year old man, previously healthy, presents with acute left sided weakness 3 hours prior to presentation that fully resolves upon initial evaluation. Thirty minutes later, he experiences right sided weakness, which again fully resolves within the span of a few minutes. He does not receive tPA. CT and MRI are then obtained and negative for acute stroke, CTA head / neck is unremarkable, and immediate cardiac studies are negative. If the patient again experiences symptoms concerning for stroke within a few hours, he would remain a candidate for tPA on the basis of the no prior history of stroke, correct? That is, the 3-4.5 hour window for tPA administration resets with each TIA if the symptoms fully resolve and / or the MRI is negative?

Also, is there any evidence of increased bleeding risk w/ tPA administration in this scenario?

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[typhoonegator]

People debate on resetting the clock. If a neurologist cannot identify a deficit after the event, I often count that as a return to baseline. If a family member cannot identify a deficit, I do not. MRI is useful if there is a DWI lesion visible, but if there isn't one visible, it could still be a stroke and should not circumvent any findings on exam which could make them ineligible for tPA. Your story sounds like a classic stuttering lacune, and I've treated them many times once the symptoms return as long as I am confident that there was a true return to baseline within the treatment window.

 

[barzan]

speaking of stuttering lacune I was just reading this, hope it helps
Stuttering Lacunes: An Acute Role for Clopidogrel?

 

[typhoonegator]

speaking of stuttering lacune I was just reading this, hope it helps
Stuttering Lacunes: An Acute Role for Clopidogrel?

Hah! I did this last night!