Thrombolytics for acute ischemic stroke

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. Clinical diagnosis of stroke
2. Clear onset (last witnessed well) <3 hours
3. Age >18 yrs

Exclusion Criteria

Absolute

1. BP Systolic >185, diastolic >110 (can receive 1-3 doses anti-hypertensive)
2. PTT >34, PT >15, or INR >1.7
3. Platelet count <100,000
4. Blood Glucose <50 or >400 mg/dl
5. Minor stroke or rapidly resolving stroke
6. Hemorrhage or edema on non-con head CT
7. Suspected SAH
8. Seizure at onset of stroke
9. Heparin treatment during the past 48 hours with an elevated PTT
10. Evidence of acute myocardial infarction

Relative

1. History of prior intracranial hemorrhage, neoplasm, AVM or aneurysm
2. Major surgery/trauma within <14 days
3. Stroke or serious head injury within 3 months
4. GI/GU bleeding within <21 days
5. Lactation or pregnancy within <30 days

Additional Per Harbor Neuro

1. AMI or pericarditis (ECG)
2. Aggressive treatment needed to control BP
3. Lumbar puncture within <7 days
4. Occult blood in urine or stool (UA + Guiac)

ECASS III Exclusion Criteria (if giving tPA between 3-4.5 hours)

1. Age > 80
2. Baseline NIHSS > 25
3. Any oral anticoagulant use
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

See Also

Neuro: post-tPA Hemmorhage

Source

1/26/06 DONALDSON (adapted from Lampe, Tintinali)

2/20/10 PANI (ACEP/AAN Guidelines--class B recommendations)