Thrombolytics for acute ischemic stroke: Difference between revisions

m (moved CVA (tPA Criteria) to CVA (tPA): this page is more than just criteria)
No edit summary
Line 1: Line 1:
== Background  ==
== Background  ==
#NINDS Trial (pts treated within 3hrs)
##Benefits:
###12% absolute risk reduction benefit (NNT = 8-9) at 3 months
####Lower percentage of pts who left hospital severely disabled
###Comparable 3-month mortality rate (even with increased rate of ICH)
##Risks:
###Intracranial hemorrhage occurs in 6.4% of treated pts
#ECASS Trial (pts treated within 4.5hrs)
##Confirmed NINDS findings even when therapeutic window extended to 4.5hr
##As a result AHA/ASA now recommends tPA for pts presenting up to 4.5hr after sx onset


#Pros:
==tPA <3hr==
##30% greater chance of good neurologic outcome at 3 months
===Inclusion Criteria===
##Comparable 3-month mortality rate
#Cons
##Intracranial hemorrhage occurs in ~5% of pts
 
*Coag results prior to tx is only required for pts on anticoagulants
*...but if history unable to be obtained must wait for coag results prior to starting tx
 
== Inclusion Criteria ==
 
#Diagnosis of ischemic stroke causing measurable neuro deficit  
#Diagnosis of ischemic stroke causing measurable neuro deficit  
#Clear onset (last witnessed well) <3hr (see below for extension to <4.5hr)  
#Clear onset (last witnessed well) <3hr (see below for extension to <4.5hr)  
#Age >18yr
#Age >18yr


== Exclusion Criteria ==
===Exclusion Criteria===
(Only need to wait for plt, INR, PTT if clinical suspicion of bleeding abnormality or thrombocytopenia, pt has received heparin or warfarin, or use of anticoagulants is unknown)
#Historical
##Stroke or head trauma in previous 3 months
##Any history of intracranial hemorrhage
##Major surgery in the previous 14 days
##GI or urinary tract bleeding in previous 21 days
##MI in previous 3 months
##Arterial puncture at noncompressible site in previous 7 days
#Clinical
##Spontaneously clearing stroke symptoms
##Only minor and isolated neurologic signs
##Seizure at onset of stroke if residual impairments are due to postictal phenomenon; #Symptoms of stroke suggestive of SAH
#Persistent SBP >185 or DBP >110 despite treatment
#Active bleeding or acute trauma (fracture) on exam
#Labs
##Platelets <100K
##Serum glucose <50
##INR >1.7 if on warfarin
##Elevated PTT if on heparin
##Use of dabigatran within 48hrs is relative contraindication
#Head CT
##Evidence of hemorrhage
##Evidence of multilobar infarction w/ hypodensity involving >33% of cerebral hemisphere


=== Absolute  ===
==tPA between 3-4.5hrs==
===Inclusion Criteria===
#Same as for <3hr


#Head trauma or prior stroke in previous 3 months
===Exclusion Criteria===
#Symptoms suggestive of SAH
#All of the above plus:
#Arterial puncture at noncompressible site in previous 7 days
##Age >80yr
#History of previous ICH
##Combination of both previous stroke and DM
#Elevated BP (sys &gt; 185 or dia &gt; 110)
##NIHSS score >25
#Active bleeding on exam
##Oral anticoagulant use regardless of INR
#Acute bleeding diathesis:
##Plt <100K
##PTT &gt; upper limit of normal
##INR &gt;1.7 or PT&gt;15 sec
#Blood Glucose <50
#CT demonstrates multilobar infarction (hypodensity &gt; 1/3 cerebral hemisphere)
 
=== Relative  ===
#Minor stroke or rapidly improving stroke symptoms
#Seizure at onset with postictal residual neuro impairments
#Major surgery or serious trauma within previous 14 days
#Acute GI or GU hemorrhage (within previous 21 days)
#Acute MI (within previous 3 months)
 
=== ECASS III Exclusion Criteria (if giving tPA between 3-4.5 hours)  ===
 
All the above absolute exclusion criteria apply, but now with the additional exclusion criteria below
 
#Age>80yr
#Severe CVA clinically (NIHSS >25) OR by imaging (e.g. involving >1/3 of MCA territory)
#Any oral anticoagulant use regardless of INR  
#History of prior stroke and DM


== Studies Needed  ==
== Studies Needed  ==
#Head CT  
#Head CT  
#CBC  
#CBC  
#PT/PTT
#Coags
#Glu check  
#Glu check  
#ECG  
#ECG  
Line 72: Line 76:


== Complications  ==
== Complications  ==
[[Post-tPA Hemorrhage]]  
[[Post-tPA Hemorrhage]]  


== See Also  ==
== See Also  ==
*[[CVA (Main)]]  
*[[CVA (Main)]]  
*[[Post-tPA Hemorrhage]]
*[[Post-tPA Hemorrhage]]

Revision as of 08:14, 28 September 2011

Background

  1. NINDS Trial (pts treated within 3hrs)
    1. Benefits:
      1. 12% absolute risk reduction benefit (NNT = 8-9) at 3 months
        1. Lower percentage of pts who left hospital severely disabled
      2. Comparable 3-month mortality rate (even with increased rate of ICH)
    2. Risks:
      1. Intracranial hemorrhage occurs in 6.4% of treated pts
  2. ECASS Trial (pts treated within 4.5hrs)
    1. Confirmed NINDS findings even when therapeutic window extended to 4.5hr
    2. As a result AHA/ASA now recommends tPA for pts presenting up to 4.5hr after sx onset

tPA <3hr

Inclusion Criteria

  1. Diagnosis of ischemic stroke causing measurable neuro deficit
  2. Clear onset (last witnessed well) <3hr (see below for extension to <4.5hr)
  3. Age >18yr

Exclusion Criteria

(Only need to wait for plt, INR, PTT if clinical suspicion of bleeding abnormality or thrombocytopenia, pt has received heparin or warfarin, or use of anticoagulants is unknown)

  1. Historical
    1. Stroke or head trauma in previous 3 months
    2. Any history of intracranial hemorrhage
    3. Major surgery in the previous 14 days
    4. GI or urinary tract bleeding in previous 21 days
    5. MI in previous 3 months
    6. Arterial puncture at noncompressible site in previous 7 days
  2. Clinical
    1. Spontaneously clearing stroke symptoms
    2. Only minor and isolated neurologic signs
    3. Seizure at onset of stroke if residual impairments are due to postictal phenomenon; #Symptoms of stroke suggestive of SAH
  3. Persistent SBP >185 or DBP >110 despite treatment
  4. Active bleeding or acute trauma (fracture) on exam
  5. Labs
    1. Platelets <100K
    2. Serum glucose <50
    3. INR >1.7 if on warfarin
    4. Elevated PTT if on heparin
    5. Use of dabigatran within 48hrs is relative contraindication
  6. Head CT
    1. Evidence of hemorrhage
    2. Evidence of multilobar infarction w/ hypodensity involving >33% of cerebral hemisphere

tPA between 3-4.5hrs

Inclusion Criteria

  1. Same as for <3hr

Exclusion Criteria

  1. All of the above plus:
    1. Age >80yr
    2. Combination of both previous stroke and DM
    3. NIHSS score >25
    4. Oral anticoagulant use regardless of INR

Studies Needed

  1. Head CT
  2. CBC
  3. Coags
  4. Glu check
  5. ECG
  6. Icon

tPA Administration

  1. Alteplase 0.9mg/kg IV (max 90mg total)
    1. Load with .09mg/kg (10% of dose) as IV bolus over 1min, followed by 0.81mg/kg (90% of dose) as cont. infusion over 60min
  2. Neuo check Q15min x 2hrs, Q30min x6hrs, Q1hr x 16hrs
  3. Keep BP <180/105
    1. Labetalol 10mg IV followed by continous IV infusion 2-8mg/min OR
    2. Nicardipine IV 5mg/h, titrate up to desired effect by 2.5mg/hr q 5-15min, maximum 15mg/h
    3. If BP not controlled or dia > 140 consider nitroprusside
  4. No anticoatulation/antiplatelets x 24hrs
  5. Stop tPA and consider head CT if pt develops:
    1. Neuro changes
    2. Acute hypertension
    3. Nausea/vomiting

Complications

Post-tPA Hemorrhage

See Also

Source

  • Tintinalli
  • Hacke W, Kaste M, Bluhmi E, et al: Thrombolysis with alteplase 3 to 4.5 h after acute ischemic stroke. N Engl J Med 359(13): 1317, 2008
  • ACEP/AAN Guidelines
  • AHA/ASA Guidelines
Retrieved from "https://www.wikem.org/w/index.php?title=Thrombolytics_for_acute_ischemic_stroke&oldid=5973"