From the Guidelines
A seizure at the onset of hemiparesis does not automatically exclude the use of tenecteplase (TNK) for stroke treatment, but it requires careful clinical evaluation. Seizures can sometimes mimic stroke symptoms or occur as the initial manifestation of a stroke. If imaging confirms an ischemic stroke and other contraindications are absent, TNK may still be considered, as suggested by the guidelines for the early management of adults with ischemic stroke 1. However, the treating physician must carefully differentiate between post-ictal Todd's paralysis and true stroke-related hemiparesis.
Key Considerations
- Standard TNK dosing for ischemic stroke is typically 0.25 mg/kg (maximum 25 mg) administered as a single intravenous bolus.
- Before administering TNK, it's essential to obtain brain imaging to rule out hemorrhage, check blood pressure (should be <185/110 mmHg), and review the patient's medical history for other contraindications such as recent surgery, trauma, or bleeding disorders, as outlined in the clinical policy for the use of intravenous tPA for the management of acute ischemic stroke in the emergency department 2.
- The decision should be made quickly within the appropriate time window (generally within 4.5 hours of symptom onset) by a stroke specialist who can weigh the benefits against potential risks in this complex clinical scenario.
Clinical Evaluation
- Careful clinical evaluation is necessary to determine the cause of the seizure and hemiparesis, and to assess the patient's eligibility for TNK treatment.
- The patient's medical history, physical examination, and imaging studies should be carefully reviewed to determine the presence of any contraindications to TNK treatment.
- The benefits and risks of TNK treatment should be carefully weighed, taking into account the patient's individual circumstances and the potential for improved outcomes with treatment.
From the Research
Seizure at Onset of Hemiparesis and Use of TNK
- The provided studies do not directly address whether a seizure at the onset of hemiparesis excludes the use of tenecteplase (TNK) 3, 4, 5, 6, 7.
- However, the studies discuss the efficacy and safety of TNK compared to alteplase for acute ischemic stroke, with some studies suggesting that TNK may be superior to alteplase in certain cases 5, 7.
- The decision to use TNK or alteplase in patients with acute ischemic stroke is typically based on factors such as the time from onset of symptoms, the severity of the stroke, and the presence of any contraindications to thrombolytic therapy 4, 6.
- Seizure at the onset of hemiparesis may be a consideration in the diagnosis and management of acute stroke, but it is not explicitly mentioned as a contraindication to the use of TNK in the provided studies.
- Further research would be needed to determine whether a seizure at the onset of hemiparesis affects the safety and efficacy of TNK in patients with acute ischemic stroke.