Thrombolytics for acute ischemic stroke

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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

(ADDITONAL 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

Giving tPA

  1. Alteplase (Activase/tPA): 0.9mg/kg (max 90mg total) IV; Give 10% as bolus over 1 min, remainder by continous infusion over 60min
  2. Neuo check Q15min x 2hrs, Q30min x6hrs, Q1hr x 16hrs
  3. Keep BP <185/95 (labetalol/nipride gtt if nec)
  4. NO anticoatulation/antiplatelet agents x24hrs
  5. Stop tPA if worsening neuro exam --> STAT head-CT

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)