Article: Sharon - Is tPA And Emergency Treatment The Only Answer?

Is tPA and Emergency Treatment the Only Answer?

Sharon - SSTattler

The newest type of medical malpractice suits are patients and their families who don’t get tPA (Avitzur).  Initially the “door to needle” time was within 3 hours of stroke, but European Cooperative Acute Stroke Study (ECASS-3) showed evidence of an expanded time window of between 3.0 and 4.5 hours for persons experiencing   acute ischemic stroke symptoms. In 2009 Neurologists, McCullough and Dearborn lamented how many people ignored the symptoms of stroke until the window for tPA has passed.

“Mrs Jones is like so many others we see on the stroke service every day. As a 64-year-old African–American female, with a history of hypertension, diabetes and poorly controlled cholesterol, she is a common face of stroke in the USA. She was working in Wal-Mart this January when her coworker noticed that her faced looked a little droopy. She ignored it, as she had no pain, until the right side of her body was so weak that she couldn’t stand up. She arrived at the emergency department more than 6 h after her symptoms started, long after the 3-h window for acute treatment with tissue plasminogen activator (rTPA) therapy had passed. When I met her, she was hemiplegic, aphasic and apraxic. Over the next several weeks she developed an ability to name simple objects and repeat simple phrases, but her right side remained paralyzed. She will probably require full-time nursing support with activities of daily living for the remainder of her life.

One frustrating aspect of stroke neurology is that once the time window for acute intervention has passed, patients can only be monitored and medical management optimized as we wait and hope for recovery. Some patients do recover remarkably well, but others remain significantly disabled or unable to resume their former functional status. This is especially true for women, who are much less likely to return to independent living compared with age-matched men.”

Now neurologists and hospitals are worried that those who arrived at the hospital in time to get tPA and didn’t get it will sue the neurologist and the hospital (Avitzur). Likely, winning such a lawsuit and receiving compensation for stroke impairments could make a significant difference to a stroke survivor’s rehabilitation and home adaptation options.

tPA has been hailed as a miracle cure for stroke impairments.  There are significant benefits to receiving tPA especially for women who have a stroke (Agarwal, 2010, Shobha,et al., 2010). Dr. Michael Hill from the Foothills Hospital in Calgary found that at post six months, women who were not given tPA had a worse quality of life than men--70 percent men performed well, but just 58 percent women rated their quality of life as acceptable on the Stroke Impact Scale. Women and men who received tPA recipient had equal quality of life results post six months. Dr. Hill thought that men who don’t get tPA do better at 6 months because they are more likely to have a caregiver, whereas women are more likely to be widowed and without family to provide care.

Even if you get tPA, it doesn’t mean that you will be completely cured.

1. tPA doesn’t work equally well in all strokes-- Because tPA attacks fibrin,  tPA is  more effective in fibrin-rich cardioembolic strokes like those caused by atrial fibrillation.  TPA is less effective with the platelet-rich thromboses from pre-existing atherosclerotic lesions. 
2. High rates of depression--After receiving tPA and a few days in hospital, many people are told how lucky they are and discharged without a rehabilitation assessment. But depression is high in patients receiving tPA-- 53% are depressed at 3 months and 42% at 12 months (Walker, 2011).
3. Less visible impairments—While people given tPA may seem fine, in other words they don’t have large motor impairments that prevent them from walking or moving their arm, they may be left with small or invisible impairments that significantly affect their day-to-day life.  For example, Cathy who was a teacher or   Jim Lee who writes the column “Wrestling with the Angels” for the Stroke Survivors Association of Ottawa both received tPA. Jim had a clot that would have left him with locked-in syndrome.  While Jim is very grateful for tPA, he still has problems with some tasks.  If you read Cathy’s story, she didn’t understand why she was struggling. She thought she should be fine. Read Cathy’s story: http://www.stroke-survivors.org/2012/04/stroke-survivors-story-of-struggle-and.html#more

So whether you tPA, or if you didn’t you still need to make sure:

1. you are assessed fully by a multidisciplinary rehabilitation team-- Physiatrist,  neuropsychologist, speech therapist, occupational therapist, and physiotherapist,  
2. you receive the rehabilitation that you need whether the problems are small or large, and
3. if you are feeling down or blue, talk to the physiatrist , neurologist, or your family doctor about the possibility of depression.

References

• Agarwal, K. (March 3, 2010). Clot-busting therapy essential for women post stroke—study.
• Avitzur, O.  As Public Expectations For tPA Grows, So Too Do Lawsuits; How Neurologists  Can Reduce Malpractice Risks.
• McCullough, L.D. Dearborn, J.(2009). Stroke-risk perception in women: getting the message out. Women’s Health; 5(3), 225-228 , DOI 10.2217/whe.09.4 
• Shobha,et al., (2010). Differences In Stroke Outcome Based On Sex. Neurology, 4:767–771
• Walker, C.  Alberta Provincial Stroke Strategy (2011, Jan) t PA Administration: Preventing Complications of Stroke (PowerPoint).
• Rehabilitation:  What Are The 50 Most Important Stroke Rehabilitation Papers?