Thrombolytics for acute ischemic stroke: Difference between revisions

No edit summary
No edit summary
Line 6: Line 6:
#Cons  
#Cons  
##Intracranial hemorrhage occurs in ~5% of pts
##Intracranial hemorrhage occurs in ~5% of pts
<br>


*Coag results prior to tx is only required for pts on anticoagulants  
*Coag results prior to tx is only required for pts on anticoagulants  
Line 15: Line 13:


#Diagnosis of ischemic stroke causing measurable neuro deficit  
#Diagnosis of ischemic stroke causing measurable neuro deficit  
#Clear onset (last witnessed well) &lt;3 hours (see below for extension to &lt;4.5 hours)  
#Clear onset (last witnessed well) <3hr (see below for extension to <4.5hr)  
#Age <u>&gt;</u>18 yrs
#Age >18yr


== Exclusion Criteria  ==
== Exclusion Criteria  ==
Line 29: Line 27:
#Active bleeding on exam  
#Active bleeding on exam  
#Acute bleeding diathesis:  
#Acute bleeding diathesis:  
##Plt count &lt; 100K&nbsp;
##Plt <100K
##PTT &gt; upper limit of normal  
##PTT &gt; upper limit of normal  
##INR &gt;1.7 or PT&gt;15 sec  
##INR &gt;1.7 or PT&gt;15 sec  
#Blood Glucose &lt;50  
#Blood Glucose <50
#CT demonstrates multilobar infarction (hypodensity &gt; 1/3 cerebral hemisphere)
#CT demonstrates multilobar infarction (hypodensity &gt; 1/3 cerebral hemisphere)


=== Relative  ===
=== Relative  ===
#Minor stroke or rapidly improving stroke symptoms  
#Minor stroke or rapidly improving stroke symptoms  
#Seizure at onset with postictal residual neuro impairments  
#Seizure at onset with postictal residual neuro impairments  
Line 47: Line 44:
All the above absolute exclusion criteria apply, but now with the additional exclusion criteria below  
All the above absolute exclusion criteria apply, but now with the additional exclusion criteria below  


#Age &gt; 80
#Age>80yr
#Baseline NIHSS &gt; 25  
#Severe CVA clinically (NIHSS >25) OR by imaging (e.g. involving >1/3 of MCA territory)
#Any oral anticoagulant use regardless of INR  
#Any oral anticoagulant use regardless of INR  
#History of prior stroke and DM
#History of prior stroke and DM


== Studies Needed  ==
== Studies Needed  ==
#Head CT  
#Head CT  
#CBC  
#CBC  
Line 62: Line 58:


== tPA Administration  ==
== tPA Administration  ==
#Alteplase 0.9mg/kg IV (max 90mg total)  
#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  
##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  
Line 86: Line 81:


== Source  ==
== Source  ==
 
*Tintinalli
1/26/06 DONALDSON (adapted from Lampe, Tintinali)
*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
2/20/10 PANI (ACEP/AAN Guidelines--class B recommendations)
*AHA/ASA Guidelines  
 
AHA/ASA Guidelines  


[[Category:Neuro]] [[Category:Procedures]]
[[Category:Neuro]] [[Category:Procedures]]

Revision as of 06:47, 28 September 2011

Background

  1. Pros:
    1. 30% greater chance of good neurologic outcome at 3 months
    2. Comparable 3-month mortality rate
  2. Cons
    1. 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

  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

Absolute

  1. Head trauma or prior stroke in previous 3 months
  2. Symptoms suggestive of SAH
  3. Arterial puncture at noncompressible site in previous 7 days
  4. History of previous ICH
  5. Elevated BP (sys > 185 or dia > 110)
  6. Active bleeding on exam
  7. Acute bleeding diathesis:
    1. Plt <100K
    2. PTT > upper limit of normal
    3. INR >1.7 or PT>15 sec
  8. Blood Glucose <50
  9. CT demonstrates multilobar infarction (hypodensity > 1/3 cerebral hemisphere)

Relative

  1. Minor stroke or rapidly improving stroke symptoms
  2. Seizure at onset with postictal residual neuro impairments
  3. Major surgery or serious trauma within previous 14 days
  4. Acute GI or GU hemorrhage (within previous 21 days)
  5. 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

  1. Age>80yr
  2. Severe CVA clinically (NIHSS >25) OR by imaging (e.g. involving >1/3 of MCA territory)
  3. Any oral anticoagulant use regardless of INR
  4. History of prior stroke and DM

Studies Needed

  1. Head CT
  2. CBC
  3. PT/PTT
  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=5965"