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Re: Stroke thrombolysis in the elderly: Risk or benefit?

We would like to comment on the risk vs. benefits decision dilemma. [1,2] As with all patients with acute ischemic stroke otherwise suitable for thrombolysis, the question boils down to determination of a “magnitude of loss” due to possible side effects in each and every case. For example, individuals with modified Rankin score 4-5 may already be disabled enough not to even consider thrombolytic therapy. We do not believe that advanced age should become the sole criterion for decision-making. The following short clinical presentation illustrates this point.

A 103-year-old right-handed woman presented to Emergency Department with nausea, increased abdominal distension and frequency of stools of 12 hours duration. She was assessed at 7:35 pm and at 7:50 pm became unable to speak, repeat words or to move her right arm and leg. She showed left head and eyes deviation and minimal somnolence, but followed commands. A right visual field defect was suspected; right lower facial weakness and right side tongue deviation were seen. She had a profound right hemiparesis and a right Babinski sign. The NIH Stroke Scale (NIHSS) was 19.

A CT scan at 8:35 pm showed generalized cerebral and cerebellar atrophy, leukoaraosis and old lacunar infarctions in the basal ganglia bilaterally. Early ischemic changes occupied less that 1/3 of the left middle cerebral artery territory. Alteplase was given after 1 hour and 15 minutes of stroke onset after extensive discussion with her relatives. Although weighting 50-52 kg, she was given t-PA for 49-50 kg to avoid overdosing. Thus, a bolus of 4.4 mg, followed by 40 mg of IV infusion over 1 hour was administered. The BP fluctuated between 189/87 and 149/71.

The head and eye deviation disappeared right after the infusion. Her right hand and leg weakness became 4/5 and the NIHSS came down to five. The CT scan after 24 hours after stroke onset showed no ischemic changes or hemorrhages. On the third day post-stroke, her speech and strength were normal.

In this case, our patient’s independence, cognitive competence and spunk shifted the decision balance towards t-PA treatment. Shortly thereafter, the patient celebrated her 104 birthday.

References

1. Hemphill JC, Lyden P. Stroke thrombolysis in elderly. Risk or benefit? Neurology 2005;65:1690-1691.

2. Engelter ST, Reichhart M, Sekoranja L, et al. Thrombolysis in stroke patients aged 80 years and older: Swiss survey of IV thrombolysis. Neurology 2005;65:1795–1798.

Send Correspondence to journal:
Re: Reply from the author

I read with interest the case discussion by Drs. Beletsky and Hachinski regarding the dilemma of risks vs benefits in the decision for thrombolysis in a 103-year-old ischemic stroke patient. It is challenging to determine overall treatment strategies from a single case report. The manner in which Drs. Beletsky an Hachinski approached this patient, including discussion with relatives prior to tPA treatment, is consistent with my approach to these patients irrespective of chronological age.