Last known well at 12:15 pm on 10/23/25. Stat CT head ruled out any acute process but showed occluded right M1 segment with some reconstitution in the right M2 and M3 segments. Neuro-stroke team consulted and recommended thrombectomy, although this was delayed until evening because another patient was being treated for similar condition by thrombectomy. Administration of tPA was not even considered, probably because the patient was on Eliquis, a blood thinner. But according to several recent studies, (see attached) this is not a contraindication if clotting times are within normal limits.
Her Protime at 1:15 pm was 11.1, her INR 0.95, and. her aPTT 34, all within normal limits. The question: Did the failure to timely administer tPA deprive the patient of a substantial probability (a jury question- could be 10% or much higher) to avoid the large permanent damage she did suffer?
Files:
No questions yet!
Do you believe there might have been medical error?
In 2025, current use of eliquis is a contraindication to tPA. Ongoing studies are investigating whether it can be given safely but right now giving tPA to a patient on Eliquis would not be standard of care (and in fact could be argued it was against standard of care)
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above. No SOC breach --> no causation.
What makes you a good expert for this case?
I am a board-certified neurologist at an academic medical center (one of the top neuroscience institute in country) and my role is a stroke attending.
How often do you encounter cases similar to this one in your practice?
I take care of 100s of patients who present with acute stroke symptoms.
Do you believe there might have been medical error?
package inset on DOAC says thrombolysis contraindicated if given within 5 days of last dose recently registry data suggests that benefit of thrombolysis on DOAC is similar to not on DOAC with not significant increased ICH risk
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
no clear evidence that thrombolysis adds significantly to the effect of thrombectomy alone for LVO - perhaps a little
What makes you a good expert for this case?
vascular neurologist with 40 years of academic clinical trials experience, part of the NINDS rt-PA Stroke Trial in the 1990s that led to FDA approval, current of this medical literature hard to fight package insert labeling guidelines
How often do you encounter cases similar to this one in your practice?
several times a year, some of which it is unclear if they actually took the DOAC and some took it the same day and some 1-2 days prior
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