Abstract 161: Repeated administration of thrombolytic therapy in the setting of stuttering lacunar infarct

Abstract

Introduction Tissue plasminogen activator (tPA) is the standard of care for the treatment of acute ischemic stroke with symptom onset within 4.5 hours. One exclusion criterion for tPA administration is stroke within 3 months due to the presumed increased risk of hemorrhage. While the rate of early recurrent stroke (ERS) within 3 months is as high as 14.5‐18.3%, the safety and effectiveness of repeated tPA administration remain unclear. An increasing number of studies pose a challenge to this recommendation. One study identified 19 patients who received tPA for ERS and found no symptomatic intracranial hemorrhage. Fifteen other studies with a cohort of 57 patients (including one patient receiving repeated tPA within 90 minutes) reached the same conclusion that repeated tPA is safe in ERS. We present a patient with stuttering motor weakness who received intravenous (IV) tPA twice, 3 days apart with discharged modified Rankin scale (mRS) of 3. Methods The patient was identified in routine clinical practice. Results Our patient is a 61‐year‐old right‐handed Caucasian woman with a medical history of untreated hypertension presented with sudden onset of left arm and leg weakness. IV tPA was given at the local emergency department (ED) and she was then transferred to our comprehensive stroke center. Upon arrival, her National Institutes of Health Stroke Scale (NIHSS) was 0. Her symptoms were completely resolved. Computed tomography (CT) head was unremarkable and CT angiography (CTA) did not show significant stenosis or occlusion. Magnetic resonance imaging (MRI) of the brain was negative for an acute infarct. She was diagnosed with a transient ischemic attack and was discharged home with aspirin and a high‐intensity statin for secondary stroke prevention. She presented to the ED the next day with identical left‐sided weakness again. Her NIHSS was 5 this time and IV tPA was given again. MRI showed an acute infarct in the right posterior limb of the internal capsule. Transthoracic echo did not reveal an intracardiac shunting or thrombus. The stroke mechanism was small vessel disease, and anti‐hypertensive medications were added to the treatment. She was discharged to an acute rehabilitation center with an mRS of 3 and her 90‐day mRS was 1 on follow up. Conclusion Management of ERS is a challenging issue in stroke care. Our case adds value to the current limited literature demonstrating the safety and effectiveness of repeated tPA in ERS, especially in patients with MR negative stuttering lacunar infarct and subsequent improvement following tPA. Further research with larger registries is needed to identify appropriate selection criteria for repeated tPA use in this patient population.