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 Inclusion Criteria

• Diagnosis of ischemic stroke causing measurable neurological deficit.

• Onset of symptoms < 3hrs before beginning treatment

• Age>18yrs

Exclusion Criteria

• Head trauma or prior stroke in previous 3 months

• Symptoms suggest subarachnoid hemorrhage

• Arterial puncture at noncompressible site in previous 7 days

• History of previous intracranial hemorrhage

• Recent intracranial or intraspinal surgery
• Intracranial neoplasm, aneurysm or AV malformation
  

• Elevated blood pressure SBP>185mmHg or DBP 110 >mmHg

• Evidence of active bleeding on examination

• Acute bleeding diathesis , including but not limited to

  • Platelet count <100000/mm³

  • Heparin received within 48hrs , resulting in an aPTT greater than the upper limit of normal

  • Concurrent use of anticoagulation with INR>1.7 or PT > 15 sec

• Blood glucose concentration <50mg/dl

• CT demonstrates multilobar infractrion (hypodensity >1/3 cerebral hemisphere)

Relative Exclusion Criteria

• Only minor or rapidly improving stroke symptoms

• Seizures at onset with postictal residual neurologic impairments

• Major surgery or serious trauma within previous 14 days

• Recent gastrointestinal or urinary tract hemorrhage (within previous 21days)

• Recent acute myocardial infraction (within previous 3mnths)

Additional Exclusion Criteria (For presentation between 3-4.5 hrs)

• Aged >80 years

• Severe stroke (NIHSS>25)

• Taking an oral anticoagulant regardless of INR

• History of both diabetes and prior ischemic stroke

Management of Hypertension

• Patient is eligible for acute reperfusion therapy except that BP is >185/110mmHg

  • Labetalol 10-20mg IV over 1-2 min, may repeat 1 time

  • Nicardipine 5mg/h IV titrate up by 2.5 mg/h every 5-15 min (Max:15mg/h)

  • Hydralazine may be considered when appropriate.

• If BP is not maintained at or below 185/110 mmHg do not administer rtPA.

• Management of BP during & after rtPA or other acute reperfusion therapy to maintain BP below 180/105

  • Blood pressure should be monitored every 15 min for 2hrs from the start of rtPA therapy , then every 30 min for 6hrs and then every 1hr for 16hrs.

  • If systolic >180-230 or diastolic >105-120 mmHg

    • Labetalol 10mg IV bolus followed by infusion 2-8mg/min

    • Nicardipine 5mg/h IV, titrate up to desired effect by 2.5mg/h every 5-15 min (Max:15mg/h)

• If BP not controlled or diastolic >140mmHg consider IV sodium nitropruside.

Administration

• rtPA (Alteplase)0.9 mg/kg (Max: 90mg) with 10% of the dose given as a bolus over 1min followed by infusion lasting 60min is recommended treatment within 3hrs of onset of ischemic stroke.

• Admit the patient to ICU or stroke unit for monitoring

• If patient develops severe headache, acute hypertension, vomiting, neurological deterioration discontinue & obtain emergency CT scan.

• Monitor BP as mentioned above.

• No other antithrombotic treatment for 24h

• Avoid uretheral cathetrisation, NG tubes , intra arterial catheters.

• Obtain a follow up CT or MRI scan at 24 hrs after IV rtPA before starting anticoagulants or antiplatelet agents.

Complication

• Hemorrhage (1.6% data from SITS- ISTR Registry)

• Stop the drug

• Send PT/INR, aPTT, Hb, PLC, Fibrinogen levels

• 4U FFP, 1U Single donor platelet, 4-6 u of cryoprecipitate

• Anaphylaxis or orolingual edema

INTRA-ARTERIAL THROMBOLYSIS

• Intra-arterial approach is considered to be efficacious for recanalization of proximal arterial occlusion than IV fibrinolysis.

• Currently it is recommended in major ischemic strokes <6hrs duration caused by occlusion of the MCA who are not candidates of IV rtPA.

• No FDA approval.

• Rescue intraarterial fibrinolysis or mechanical thrombectomy may be reasonable when IV rtPA fails.

Notes:

• Persons on aspirin are eligible for thrombolysis if other criteria are satisfied.

Reference

• American Stroke Association :2013 Guidelines.

Updated on 2/2/2015.