View source for Thrombolytics for acute ischemic stroke

==Background==
''[[EBQ:Studies_List_of_Thrombolytics_for_Acute_Stroke|see list of all thrombolytic trials in CVA for more details]]''
===NINDS Trial (treated within 3hrs)===
Benefits: 
*12% absolute risk reduction benefit (NNT = 8-9) at 3 months 
*Lower percentage of patients who left hospital severely disabled
*Comparable 3-month mortality rate (even with increased rate of ICH)
Risks:
*1% increase in mortality
*5% increase in nonfatal intracranial hemorrhage
===ECASS Trial (treated within 4.5hrs)===
*Confirmed NINDS findings even when therapeutic window extended to 4.5hr
*As a result AHA/ASA now recommends tPA for patients presenting up to 4.5hr after symptom onset

==Studies Required==
*Physical exam: [[NIH Stroke Scale]]
*[[Head CT]] 
*CBC (hemoglobin, plt)
*PT/PTT/INR
**Only need to wait for result if suspicion of abnormal value, patient has received heparin or warfarin, or use of anticoagulants is unknown
*Glucose 
*[[ECG]] 
*Urine pregnancy (pregnancy is relative contraindication)

==tPA <3hr==
===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===
*Historical
**[[Stroke]] or [[head trauma]] in previous 3 months
**Any history of [[intracranial hemorrhage]]
**Major surgery in the previous 14 days
**[[GI bleed|GI]] or [[hematuria|urinary tract]] bleeding in previous 21 days
**[[Myocardial infarction]] 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 stroke onset
*Persistent [[hypertension|SBP >185]] or DBP >110 despite treatment
*Use of direct thrombin inhibitors (e.g. [[dabigatran]], [[argatroban]]) or direct factor Xa inhibitors (e.g. [[rivaroxaban]], [[apixaban]]) with elevated aPTT, INR, or factor Xa assay
*Active bleeding or acute [[trauma]] ([[fracture]]) on exam
*Labs
**Platelets <100K
**Serum glucose <50, >400
**INR >1.7 or PT >15 sec if on warfarin
**Elevated PTT if on heparin
*[[Head CT]]
**Evidence of [[ICH|hemorrhage]]
**Evidence of multilobar infarction with hypodensity involving >33% of cerebral hemisphere
**Intracranial neoplasm, [[AVM]], or aneurysm
*Use of dabigatran within 48hrs is relative contraindication

===Relative Exclusion Criteria===
*Minor or rapidly improving stroke symptoms
*[[Pregnancy]]
*[[Seizure]] at onset with postictal residual neuro impairments

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

===Exclusion Criteria===
*All of the above plus:
**Age >80yr
**Combination of both previous stroke and DM
**NIHSS score >25
**Oral [[anticoagulant]] use regardless of INR

==Administration==
{{TPA Stroke}}

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

==See Also==
*[[CVA (Main)]] 
*[[Post-tPA Hemorrhage in CVA]]
*[[NIH Stroke Scale]]
*[[EBQ:Studies List of Thrombolytics for Acute Stroke|List of studies: Thrombolytics in CVA]]
*[[Thrombolytics]]

==References==
*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 

[[Category:Neurology]] 
[[Category:Procedures]]