Thrombolytics for acute ischemic stroke
(Redirected from Thrombolysis in Acute Ischemic Stroke (tPA))
Background
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 or 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 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 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
Alteplase
- NOTE - in stroke, do not give aspirin until 24 hours after giving tPA, as ASA with tPA does not improve outcomes and increases bleed risk[1]
- Do not give acutely heparin (or any anticoagulation) if giving tPA[2]
Dosing:
- 0.9mg/kg IV (max 90mg total)
- 10% of dose is administered as bolus; rest is given over 60min
- Neuro check Q15min x 2hr
- No anticoagulation/antiplatelets x 24hr
- Blood pressure (keep SBP <180, DBP <105)
If SBP is >180-230 or DBP is >120:
- Nicardipine 5 mg/hr by slow infusion (50 mL/hr) initially; may be increased by 2.5 mg/hr every 15 minutes; not to exceed 15 mg/hr OR
- Labetalol 10mg IV over 1–2 min; repeat dose q10–20min up to 300mg max OR
- Labetalol 10mg IV followed by infusion at 2–8 mg/min
If BP not controlled by above measures:
- Nitroprusside 0.5–10mcg/kg/min
- Continuous arterial monitoring advised
- Use with caution in patients with hepatic or renal insufficiency
tPA Complications
See Also
- CVA (Main)
- Post-tPA Hemorrhage in CVA
- NIH Stroke Scale
- 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
- ↑ Zinkstok SM, Roos YB, ARTIS Investigators . Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial. Lancet (2012) 380(9843):731–7.10.1016/S0140-6736(12)60949-0.
- ↑ Periprocedural Antithrombotic Treatment During Acute Mechanical Thrombectomy for Ischemic Stroke: A Systematic Review. Rob A. van de Graaf, Vicky Chalos, Gregory J. del Zoppo, Aad van der Lugt, Diederik W. J. Dippel, Bob Roozenbeek. Front Neurol. 2018; 9: 238.