Stroke Treatments - do not malign tPA. One day, it can save your own brain

I was called by ER regarding a very functional lady in her late 60s who suddenly developed difficulty speaking and promptly worsens to include paralysis on the left arm and leg. By the time I saw her, the paralysis and slurred speech worsened to an NIHSS of 12. It was 2 hours since her stroke onset. The patient's daughters were presented treatment options literature that instilled fear of bleeding if a certain drug is infused (tPA). They wanted a catheter put into the arteries and the clot causing the stroke "pulled out". I quickly point out that the FDA approved treatment is still IV tPA. In fact, the treatment window has been expanded up to 4.5 hours from the time stroke onset. I have seen the MERCI and even the PENUMBRA devices used since I took the job as co-Medical Director of Central DuPage Hospital Stroke and Neurovascular Program 5 years ago. These are wonderful and clever devices and more often than not, helps re-canalize an occluded vessel. However, like tPA, if blocked arteries are opened up, reestablishing flow into vessels that are rendered "leaky" due to lack of oxygen, also increases the risk of bleeding. Finally, threading those catheters into tortuous vessels can be a technological challenge that I have seen great expectations vanish into thin air, as the interventionalist struggles to pass its tip through kinked or tortuous vessels. This particular patient's daughters reluctantly accept my order to proceed with the IV tPA but as a compromise, I gave partial loading, leaving some amount available for the Interventionalist to use intra-arterially in case he needed to go in later. The patient improves 100% and the MRI does not show any trace of minor stroke.