Thrombolytics for acute ischemic stroke: Difference between revisions
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==Background==
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# Pros:
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## 30% greater chance of good neurologic outcome at 3 months
| Table Test
## Comparable 3-month mortality rate
| Table Test
# Cons
|-
## Intracranial hemorrhage occurs in ~5% of pts
| <br/>
| <br/>
|-
| <br/>
| <br/>
|}


== <br/> ==


* Coag results prior to tx is only required for pts on anticoagulants
== Background ==
* ...but if history unable to be obtained must wait for coag results prior to starting tx


==Inclusion Criteria==
#Pros:
# Diagnosis of ischemic stroke causing measurable neuro deficit
##30% greater chance of good neurologic outcome at 3 months
# Clear onset (last witnessed well) <3 hours (see below for extension to <4.5 hours)
##Comparable 3-month mortality rate
# Age >18 yrs
#Cons
##Intracranial hemorrhage occurs in ~5% of pts


==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 count < 100K
## PTT > upper limit of normal
## INR >1.7
# 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)===
*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) <3 hours (see below for extension to <4.5 hours)
#Age >18 yrs
 
== 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 count < 100K
##PTT > upper limit of normal
##INR >1.7
#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) ===
 
#Age > 80
#Age > 80
#Baseline NIHSS > 25
#Baseline NIHSS > 25
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#History of prior stroke and DM
#History of prior stroke and DM


==Studies Needed==
== Studies Needed ==
# Head CT
 
# CBC
#Head CT
# PT/PTT
#CBC
# Glu check
#PT/PTT
# ECG
#Glu check
# Icon
#ECG
#Icon
 
== 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
#Neuo check Q15min x 2hrs, Q30min x6hrs, Q1hr x 16hrs
# Neuo check Q15min x 2hrs, Q30min x6hrs, Q1hr x 16hrs
#Keep BP <180/105
# Keep BP <180/105
##Labetalol 10mg IV followed by continous IV infusion 2-8mg/min OR
## 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
## 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
## If BP not controlled or dia > 140 consider nitroprusside
#No anticoatulation/antiplatelets x 24hrs
# No anticoatulation/antiplatelets x 24hrs
#Stop tPA and consider head CT if pt develops:
# Stop tPA and consider head CT if pt develops:
##Neuro changes
## Neuro changes
##Acute hypertension
## Acute hypertension
##Nausea/vomiting
## Nausea/vomiting
 
== See Also ==


==See Also==
[[Post-tPA Hemorrhage]]
[[Post-tPA Hemorrhage]]


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


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AHA/ASA Guidelines
AHA/ASA Guidelines


[[Category:Neuro]]
<br/>[[Category:Neuro]] <br/>[[Category:Procedures]] <br/><br/><br/>
[[Category:Procedures]]

Revision as of 16:16, 26 June 2011

Table Test Table Test





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) <3 hours (see below for extension to <4.5 hours)
  3. Age >18 yrs

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 count < 100K
    2. PTT > upper limit of normal
    3. INR >1.7
  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)

  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

Post-tPA Hemorrhage

Source

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

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

AHA/ASA Guidelines






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