Thrombolytics for acute ischemic stroke: Difference between revisions
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Revision as of 07:40, 28 September 2011
Background
- Pros:
- 30% greater chance of good neurologic outcome at 3 months
- 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
- Clear onset (last witnessed well) <3hr (see below for extension to <4.5hr)
- Age >18yr
Exclusion Criteria
Absolute
- Head trauma or prior stroke in previous 3 months
- Symptoms suggestive of SAH
- Arterial puncture at noncompressible site in previous 7 days
- History of previous ICH
- Elevated BP (sys > 185 or dia > 110)
- Active bleeding on exam
- Acute bleeding diathesis:
- Plt <100K
- PTT > upper limit of normal
- INR >1.7 or PT>15 sec
- Blood Glucose <50
- CT demonstrates multilobar infarction (hypodensity > 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
- Head CT
- CBC
- PT/PTT
- Glu check
- ECG
- Icon
tPA Administration
- Alteplase 0.9mg/kg IV (max 90mg total)
- 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
- Neuo check Q15min x 2hrs, Q30min x6hrs, Q1hr x 16hrs
- Keep BP <180/105
- Labetalol 10mg IV followed by continous IV infusion 2-8mg/min OR
- Nicardipine IV 5mg/h, titrate up to desired effect by 2.5mg/hr q 5-15min, maximum 15mg/h
- If BP not controlled or dia > 140 consider nitroprusside
- No anticoatulation/antiplatelets x 24hrs
- Stop tPA and consider head CT if pt develops:
- Neuro changes
- Acute hypertension
- Nausea/vomiting
Complications
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