Can rt-PA be Administered to the Wrong Patient? Two Patients with Somatoform Disorder

• Published in: Canadian journal of neurological sciences 2004-02, Vol.31 (1), p.99-101
• Main Authors: Mouradian, Mikael S., Rodgers, Jennifer, Kashmere, Jodi, Jickling, Glen, McCombe, Jennifer, Emery, Derek J, Demchuk, Andrew M., Shuaib, Ashfaq
• Format: Article
• Language: English
• Subjects: Acute Disease; Aged; Aged, 80 and over; Biological and medical sciences; Diagnosis, Differential; Diagnostic Errors - adverse effects; Female; Humans; Infusions, Intravenous; Male; Medical sciences; Middle Aged; Neurologic Examination; Neurology; Recombinant Proteins - administration & dosage; Recombinant Proteins - adverse effects; Recombinant Proteins - therapeutic use; Somatoform Disorders - diagnosis; Somatoform Disorders - drug therapy; Stroke - diagnosis; Stroke - drug therapy; Thrombolytic Therapy - adverse effects; Thrombolytic Therapy - methods; Tissue Plasminogen Activator - administration & dosage; Tissue Plasminogen Activator - adverse effects; Tissue Plasminogen Activator - therapeutic use
• ISSN: 0317-1671; 2057-0155
• DOI: 10.1017/S0317167100002900

Intravenous rt-PA (i.v. rt-PA) for acute stroke has raised many concerns, including its inadvertent use in patients presenting with acute stroke-like symptoms as the expression of their somatoform disorder. Diagnosis of the somatoform disorder is often delayed, and thrombolytics in these patients for their stroke-like presentation subjects them to risk for hemorrhage. The presentation, neurological findings, and the therapeutic decision making was audited in 85 patients who received i.v. rt-PA for a diagnosis of acute stroke. All the surviving patients were re-examined neurologically at least three months after i.v. rt-PA. Baseline and follow-up brain CT scans were re-reviewed by a neuroradiologist who was blinded to clinical presentation and outcome. Patients whose clinical presentation, brain CT and neurological outcome did not fit into known or expected anatomical and clinical patterns of stroke underwent psychological assessment using the Minnesota Multiphasic Personality Inventory-2. In two patients three stroke-like presentations of somatoform disorder inadvertently were treated with i.v. rt-PA. This was primarily caused by abbreviated neurological examination and narrow differential diagnosis. Patients with somatoform disorder may present with symptoms mimicking acute stroke. Under the time constraints of i.v. rt-PA use, a diagnosis of somatoform disorder can be missed, subjecting such patients to the potential complications of thrombolytics.