Q: I was talking to a 63-year-old friend who had recently had a stroke. He has always had high blood pressure, but now he has a paralyzed right arm and a little drooping of the face on one side. He seems to walk OK. I asked him if he was given the clot-busting treatment in the emergency department. He said no because he didn’t want it because he didn’t want to bleed to death. Can this happen? Do you think that getting this treatment is a good thing or not? I always thought that if you got to the hospital in time, it could save you from being paralyzed.
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A: Tissue Plasminogen Activator (tPA) is a substance that can dissolve blood clots so it is known as the clot-busting drug. It is used in the treatment of most heart attacks and strokes in the United States, if the patient fits certain criteria. In 1996, the U.S. Food and Drug Administration approved the use of tPA to treat ischemic stroke in the first three hours after the start of symptoms.
This makes it important to seek help immediately
if a person thinks he is having a stroke. If given promptly, tPA can significantly reduce the effects of stroke and
reduce permanent disability such as paralysis or weakness of limbs and speech problems.
There are some circumstances where it is not used. If the person has extremely high blood pressure, in the range of 185 over 110 or higher, tPA treatment could cause a cerebral hemorrhage, or bleeding into the brain. Also, if the stroke is mild and the patient is recovering rapidly, the doctor may feel that the risks outweigh the benefits.
Anyone who is already taking blood thinner such as Coumadin or Warfarin should not be given the treatment. The same applies to people who have low platelet counts below 100,000 because their blood is already thin. It is also important for the doctors to establish that a stroke is due to a blood clot and not a cerebral hemorrhage.
Finally, if the heart attack or stroke occurred more than three hours before arrival in hospital, then the tPA will not be effective.
There is a one in 16 chance that tPA treatment can cause a hemorrhage, so some doctors in Canada are reluctant to use it. In smaller community hospitals, it is more likely that tPA will not be used because some expertise is required to administer the treatment, which is intravenous.
There is ongoing controversy and discussion in the Canadian Journal of Emergency Medicine about limiting the use of this treatment to specialty centres. That probably means larger teaching hospitals.
In the case of your friend, you mention he has high blood pressure, so the stress of the situation may have pushed it up to the range where tPA treatment could be dangerous, or perhaps he was just unfortunate enough to have gone to the wrong emergency department. Unfortunately, it sounds as though he will be left with some permanent disability.
TPA is the only active treatment for strokes. Medications such as Coumadin and ASA are often given after the event to prevent further episodes. There is always a risk of a further massive stroke or heart attack in the first 48 hours after the first one.
Clare Rowson is a retired medical doctor living near Belleville, Ont. Her columns are intended for general information only. Individuals are encouraged to also seek the advice of their own doctor regarding medical questions and treatments.
