A 75 y/o female presents after falling while on the way to the bathroom. She is brought by EMS and noted to have a dense hemiparesis on the right. Family noted she had gotten out of bed to go to the bathroom when she fell. They heard the ‘thump’ and when they got there, they noted she wouldn’t talk. She also could not walk, so they called EMS.
PMH: Per family: hypertension and keloids.
Per family, patient was fine when she went to bed < 1 hour earlier.
PE: 97F, P=91, RR=18, BP=114/72, Sat=97%. In general, she appears mute and obtunded. She will follow some simple commands.
HEENT: Eyes deviated to Left, PERRL, and neck supple.
Heart: Irregular rhythm
Lungs: Clear bilaterally
Abd: Soft, non-tender
Ext: Unremarkable
Neurologic: Difficult exam - Generally obtunded, unable to speak, can follow some simple commands (such as open and close eyes), Forced deviation of eyes, minor facial paralysis, unable to move right arm, and left arm weak. The right leg is weak as well.
NIHSS score = 22
Answers:
1. What is the maximum NIHSS score?
The NIHSS stands for National Institute of Health Stroke Scale (NIHSS) Score. It is a method to objectively and numerically quantify the degree of neurologic deficit. It is similar to the Glasgow coma score, which numerically quantifies the degree of alteration in consciousness. It is somewhat more detailed than the GCS, and is becoming a required element for all patients with strokes. Understanding the arrival NIHSS score, and comparing it to subsequent scores, allows for an evaluation of whether the patient is improving with time, or getting worse. Additionally, in order to give TPA you need to calculate the score because if the score is very low (as it would be if a patient only had a mild sensory loss), the patient would not be a TPA candidate. To calculate the NIHSS score, see this link: http://strokecenter.stanford.edu/scales/nihss.html .
A free online teaching module is available in several languages (you will need to register, but it is free). Available at: http://www.nihstrokescale.org/links.shtml
The maximum NIHSS score is actually 42, however as most patients have unilateral symptoms, the maximum score for a stroke patient (previously normal) with complete hemiparesis, heminopia, hemineglect and aphasia is actually 31. The minimum score is 0.
It usually takes between 5-8 min to do the scale, and as with anything, you get better the more you do it.
2. Is this patient a candidate for Intravenous TPA? What score is too low? Too high for treatment?
Many experts consider patients with NIHSS scores of 4 and up (assuming no contraindications exist) candidates for TPA. (1) Patients with scores less than 4 may not have severe deficits, and the risk may not warrant treatment. The FDA-approved package insert for TPA lists a NIHSS score greater than 22 as a warning for giving TPA, as these patients have a greater risk of bleeding. These patients (with NIHSS scores>22) also are likely to benefit from treatment, so many experts still give TPA with NIHSS >22. (1) Of note, in a consensus published in 2006, experts considered TPA in patients with NIHSS scores of 2-3 and more as reasonable TPA candidates. (2)
Currently this patient is not a candidate for TPA until the CT is negative for bleeding. (3) Other exclusion criteria should also be met. (3)
3. What is the time cutoff for intravenous TPA?
In the NINDS trial, the cutoff was 3 hours after symptom onset. However, 2 more recent studies suggest the time cutoff can be extended to 4.5 hours. (1). The American Heart Association/American Stroke Association guidelines for giving TPA in strokes were revised in May 2009 to include patients in the 3-4.5 hour window (4, 5) Although TPA is not FDA approved in this time frame.
Outcome:
Patients CT was negative for bleed. She had no contraindications to TPA, and after a discussion with family and neurology, she was given TPA at 2.5 hours into the event. Unfortunately, she never improved (actually got worse although not from a hemorrhagic conversion, likely from edema) and ultimately was made Hospice.
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References:
1. Saver JL, Kalafut M. Thrombolytic Therapy in Stroke. Emedicine Aug 11, 2009. Accessed at: http://emedicine.medscape.com/article/1160840-overview
2. Dirks M, Niessen L, Koudstaal PJ, Franke C, van Oostenbrugge RJ, and Dippel DW. Intravenous thrombolysis in acute ischaemic stroke: from trial exclusion criteria to clinical contraindications. An international Delphi Study. J Neurol Neurosurg Psychiatry 2007; 78; 685-689. Accessed at: http://jnnp.bmj.com/content/78/7/685.abstract
3. Guidelines for Early Management of Adults with Ischemic Stroke. AHA/ASA Guideline. Stroke, 2007; 38:1655. Entire manuscript available at: http://stroke.ahajournals.org/cgi/content/full/38/5/1655
4. Becker JE< Wira CR, Arnold JL. Stroke, Ischemic: Treatment and Medication. Emedicine June 19, 2009. Accessed at: http://emedicine.medscape.com/article/793904-treatment
5. Zoppo GJ, Saver JL, Jauch EC, Adams HP et al. Expansion of the Tie Window for Treatment of Acute Ischemic Stroke with Intravenous tissue Plasminogen Activator: A Science Advisory from the American Heart Association/American Stroke Association. Stroke 2009; 40; 2945-2948 Entire manuscript accessed at: http://stroke.ahajournals.org/cgi/reprint/STROKEAHA.109.192535
6. Nedeltchev K, Schwegler B, Haefeli T, Brekenfeld C, et al. Outcome of Stroke with Mild or Rapidly Improving Symptoms. Stroke 2007; 38:2531. Entire manuscript accessed at: http://stroke.ahajournals.org/cgi/content/full/38/9/2531