AcuteCare Telemedicine Blog


The Personal Side of Acute Stroke Intervention

Mr. Rigby was found unresponsive, gazing to the right and unable to move his left side. Just moments ago, his nurse had seen the 91 year old awake in his hospital bed preparing himself for discharge from the hospital. Though the hospital lacked a neurologist, it had invested in telemedicine services. Immediate assessment of his acute neurological deficits would determine whether treatment with tissue plasminogen activator (tPA), a clot-busting medication, or even thrombectomy (direct mechanical extraction of the clot) was appropriate. If performed within a very short time window, tPA or thrombectomy would open arteries and prevent progressive death of brain cells. However, it could also lead to hemorrhage, bleeding into the brain that could be devastating and even life-threatening. Thus, the teleneurologist was charged with not simply recognizing Mr. Rigby’s stroke symptoms, but also those factors which make the risk greater than the benefit.

As the AcuteCare Telemedicine physician on call, I was at the bedside within minutes via remote presence technology. The evidence; left hemiparesis, left visual field loss and inability to speak, made it clear; Mr. Rigby had sustained a large right hemisphere stroke. A large artery, the MCA, was blocked by clot. His nurse knew the exact time of symptom onset. Without treatment he may have survived, but it was likely he would not walk or talk. He met every inclusion criteria for tPA. Unfortunately, Mr. Rigby was not a good candidate. He had undergone a surgical procedure just the day before, his anticoagulation had been restarted that day and his platelets were very low. At the age of 91 years with these risk factors, the likelihood of serious hemorrhage was too great. As I informed the family members that had filled the hospital hallways, a look of desperation filled their eyes. His daughter stated, “This man is worth-saving.” Remembering my Hippocratic Oath, my immediate response in this case was, “I am certain he’s worth saving, but nobody is worth harming.”

Then I remembered this “case” was her father. I asked her to tell me more about Mr. Rigby. A picture of a family patriarch emerged. He was still vigorous, taking walks daily. He was driving. Indeed, he still routinely played 9 holes of golf. But what she told me next illustrated the shortcoming of using population-based inclusion and exclusion criteria as the sole determinant of risk-benefit for an individual. Mr. Rigby was the caretaker of his 89 year old disabled and blind wife. Without the ability to walk and speak not only Mr. Rigby would suffer. I made an immediate call to the Marcus Stroke Center at Grady Memorial Hospital in Atlanta. The Marcus Center stroke physician agreed the criteria for invasive intervention suggested a high risk, but Mr. Rigby would be given a chance because the potential for benefit was irrefutable. Within a few hours the clot was extracted. Mr. Rigby had an opened artery with full reperfusion. His symptoms improved with only residual left arm weakness. Though speaking slowly, his good humor was immediately apparent. A family had their patriarch back.


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