History of Present Illness: A man in his late 30’s with no PMH is brought to the ED by medics for sudden confusion and ataxia while driving.  He denies any headache or other complaints.  On exam e has right facial droop and diplopia but no other deficits.

Testing reveals a head CT that is read by radiology as negative and soon thereafter he was treated with TNK.   His CTA shows occlusion of the left vertebral artery from a suspected dissection.  The basilar artery is clear and neither neurology nor IR recommend thrombectomy for the vertebral artery occlusion.

About 20 minutes after finishing the TNK the nurse calls you because he is short of breath.  He seems to be struggling a bit and not handling secretions great.  There is no rash or hypotension or wheezing, but his tongue seems enlarged so you treat for possible anaphylaxis, a known risk with TPA, with IM epi, and IV Benadryl and steroids.

Ten minutes later the nurse calls you back because he is unresponsive and gurgling.  He looks much worse, but the tongue looks the same as far as you can tell.  Still no rash and blood pressure is in the 180’s, but the pulse ox dropped to the 40’s and heart rate is now in the 40’s as well.  You are worried about a bleed and a Cushing’s response causing bradycardia.  Your next step is to intubate the patient, which you do successfully.

What should you do next?

  • A) Give cryoprecipitate and other meds to reverse TNK then repeat CT
  • B) No meds but repeat the head CT
  • C) Give a second dose of epinephrine for anaphylaxis
  • D) Aggressive IV antihypertensives and call neuro to the bedside

 

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

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ANSWER: What should you do next?

  • A) Give cryoprecipitate and other meds to reverse TNK then repeat CT – No as these symptoms could be progression of the stroke instead of a bleed
  • B) No meds but repeat the head CT – CORRECT – you need to definitively rule in or rule out a bleed before deciding how to treat, even if the patient is critical
  • C) Give a second dose of epinephrine for anaphylaxis – only if overt signs of anaphylaxis persist.  Epi could make a bleed worse or increase the risk of a new one
  • D) Aggressive IV antihypertensives and call neuro to the bedside – dropping BP too fast can make stroke worse.  After TPA treatment goals are to keep BP <185/110 (without TPA it would be 220/120)

1-Minute Consult on this topic: Click HERE and scroll to page 188.

Brain bleed p TPA: 

  • Suspected:  Don’t treat empirically as if no bleed BP drop or FFP, etc. can worsen stroke!
  •                       Stop tPA, elevate HOB, repeat CT/coags/CBC & get fibrinogen & plt fxn assay
  • Confirmed: Keep BP <160, give 10u cryo (if unavailable use tranexamic acid 1g), consult
  •                       If fibrinogen <150 give FFP & more cryo, platelets if <100, FFP or PCC if ­INR

 

CASE CONCLUSION: repeat CT and CTA are unchanged with no bleed or progression of disease in the left vertebral artery.  CT the next day shows a cerebellar stroke.  MRI showed strokes in CBL, L thalamus, brainstem, L occipital lobe and the medulla all from a vertebral artery dissection.