Presentation

Jack Kessler is an active 64-year-old man who enjoys fishing, playing with his grandchildren, and working on his house. While on an out-of-state fishing trip with his brother-in-law, this nonsmoking chemical engineer experienced sudden dizziness, sensory loss, and ataxia of the left face, arm, and leg. He arrived at the emergency department (ED) within 65 minutes from onset of symptoms.

Medical/surgical history

Mr. Kessler has a history of acid reflux disease, elevated cholesterol, and lower back pain with numbness in the right leg, subsequent to prior surgery. Mr. Kessler also has a family history of stroke affecting his mother and sister. He has had no recent surgery or trauma, and has no history of stroke, myocardial infarction, shortness of breath, or headache. Mr. Kessler takes quinine, simvastatin (a proton pump inhibitor for acid reflux), and azelastine (nasal spray for allergic rhinitis).

Significant findings

Radiology A head CT scan without contrast is ordered upon admission and shows no evidence of bleeding, infarction, or midline shift. In-hospital echocardiogram with contrast shows no source of cardiac embolus, and MRIs of the head and carotid arteries show no evidence of stenosis or aneurysm.

Diagnosis/assessment

The ED physician makes the diagnosis of an acute stroke. Mr. Kessler is considered a good candidate for thrombolysis and has no contraindications. He gives informed consent in the ED.

Treatment/outcome

Mr. Kessler is given Activase (t-PA) in accordance with dosing guidelines (0.9 mg/kg infused over 60 minutes, not to exceed 90 mg total dose). His symptoms begin to resolve within 10 minutes, and he is admitted into the hospital for observation. He is discharged home after 2 days with nearly complete resolution of his symptoms.

In his own words

Dear Doctor,

I apologize for my delayed correspondence and would like to express my gratitude towards you. You treated me with Activase when I had a stroke while on a fishing trip with my brother-in-law. Since my recovery, I have been busy fishing and spending time with my beautiful wife.

While it all still seems like a bad dream, I can remember being put through a series of tests, like smiling and foot and hand resistance, to see how my stroke was progressing. I was horrified to realize that I could not complete any of the exercises on my left side. I could see that I was facing the possibility of being a prisoner in my house or a nursing home, which is why I did not hesitate to try Activase. I weighed the risk of a potential bleed against the thought of not being able to play with my grandkids, so the decision to use Activase was easy for me.

I was able to wave my left hand within 10 minutes of receiving treatment, and regained mobility on my whole left side within 15 minutes. Two months after my stroke, I felt that I was once again my usual self. I am grateful to you for providing me with excellent care, and for the chance to return to the people and life that mean so much to me.

Sadly, the fish are not as grateful.

Sincerely,

Jack Kessler

Lifetime fisherman and Activase (t-PA) patient

Case drawn from actual patient. Individual results may vary.

Presentation

Louis Milone is a married, 47-year-old white male with no significant past medical problems. His family history, however, includes diabetes, hypertension, and cerebrovascular disease. Louis is a social drinker, but a heavy smoker (2 packs per day). At the time of admission, he was complaining of dizziness followed by a sudden onset of left-sided weakness with facial droop and slurred speech.

Medical/surgical history

Mr. Milone has had no recent surgical procedures or trauma. There is no history of shortness of breath, chest or abdominal pain, fever or chills, or headache. Mr. Milone does not take any prescription medications and has no known drug allergies.

Significant findings

Radiology A head CT scan without contrast shows moderate atrophy but no evidence of intracranial hemorrhage. An in-hospital ultrasound reveals bilateral carotid stenosis. For illustrative purposes only. CT scan courtesy of Bart M. Demaerschalk, MD, MSc, FRCPC. Reprinted with permission.

Diagnosis/assessment

Because stroke is suspected, a CT of the brain without IV contrast is quickly ordered and performed. There is no evidence of intracerebral hemorrhage but there is moderate atrophy. A diagnosis of a right middle cerebral infarct is made. Based upon these findings and the absence of any contraindications for t-PA, Mr. Milone is considered to be a good candidate for thrombolysis. Diagnoses of hypertension and diabetes are also made at time of admission, and although Mr. Milone's blood glucose is greater than 400 mg/dL, it was ruled out as a cause of his symptoms.

Treatment/outcome

Mr. Milone is given Activase (t-PA) in accordance with dosing guidelines (0.9 mg/kg infused over 60 minutes, not to exceed 90 mg total dose), and admitted to the telemetry unit. He is discharged to a rehabilitation center after 6 days with planned carotid surgery after 3 months.

In his own words

Dear Doctor,

I never gave much thought to the hospital in our town, other than knowing how to get there in an emergency. I certainly knew nothing about stroke treatment and the importance of an emergency room equipped to handle this. I do now.

Unbeknownst to my wife Christine and I, we live right down the road from a top-ranked* stroke care hospital. She had no idea what was wrong with me when she called 911 after I suddenly began to slur my speech and could not move my left side. She suggested the closest hospital when asked by EMS, and thankfully so. Everything happened so quickly, and I now have a better understanding of the urgency of stroke reaction and treatment. Because Christine reacted immediately, I arrived at the hospital quickly, and because the hospital was so prepared to treat stroke, you were able to give me Activase within the 3-hour window.

It has been a long road to recovery for me following my stroke. Over a year later, I still tire easily and sometimes have trouble finding the right word. Whenever I feel 'down,' I think of the alternative — greater disability or even death. From that perspective, I am more than happy to be 90% recovered.

Thank you.

Sincerely,

Louis Milone

Devoted husband and Activase (t-PA) patient

Case drawn from actual patient. Individual results may vary.

• *
• Tenth Annual HealthGrades Hospital Quality in America Study. 10/16/07. www.healthgrades.com.

Presentation

Julie Jensen is an athletic 26-year-old female who loves running, yoga, and the challenge of a triathlon. A Web designer by profession, Julie is a nonsmoker with no known risk factors for stroke. She reports that she was sitting at her computer at work when she looked down at her left arm and didn't recognize it as her own. Her coworkers noted that her face seemed to droop and her speech was slurred. At that time, emergency services were called and Ms. Jensen was brought to a certified stroke center, bypassing other uncertified hospitals along the route. She arrived at the hospital within 35 minutes of symptom onset.

Medical/surgical history

Ms. Jensen has no significant medical history and no recent history of surgical procedures or trauma. She takes oral contraceptives but no other prescription medications. Ms. Jensen has no known drug allergies.

Significant findings

Radiology A head CT scan initiated within 22 minutes of arriving in the emergency department shows no evidence of intracranial hemorrhage. Hyperdensity in the region of the right middle cerebral artery suggests an acute ischemic stroke.

Diagnosis/assessment

Initial assessment is completed by the admitting physician within 55 minutes of the acute onset of symptoms. A head CT is ordered and interpreted within 30 minutes of arrival at the hospital, at which point the decision is made to initiate thrombolysis.

Treatment/outcome

Ms. Jensen is administered Activase (t-PA) in accordance with dosing guidelines (0.9 mg/kg body weight infused over 60 minutes, not to exceed 90 mg total dose). Door-to-needle time is 60 minutes. Her primary symptoms resolve following treatment, and she is discharged home 9 days later with lingering difficulties related to concentration and time/spatial orientation disturbances that resolve over a period of 1 year.

In her own words

Dear Doctor,

I thought strokes were for the elderly and those with high blood pressure or obesity — certainly not for me! I was a 26-year-old triathlete in good health and recently engaged to be married. Since I was athletic and had extremely low blood pressure and low cholesterol, I assumed I was the picture of health. If my coworkers had not recognized the signs and symptoms (slurred words, left arm paralysis) and called 911, I may not have been here to write, because I would never have believed that I was having a stroke.

My good fortune began when my ambulance bypassed other local hospitals to take me to the nearest stroke center. I was frightened when I was counseled on the benefits and risks of Activase, but I knew the chance of surviving with little to no disability was well worth the risk.

Since my stroke, I have married my fiancé, and I continue to enjoy running and daily yoga classes. I was just elected to the board of the Bay Area American Stroke Association. I became involved because I want to make sure that more stroke victims, regardless of age, are appropriately treated and offered the opportunity to share my outcome.

And for that outcome, I am eternally thankful.

Sincerely,

Julie Jensen

Triathlete and Activase (t-PA) patient

Case drawn from actual patient. Individual results may vary.