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emmedonline
Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor
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
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.
Extended Window for Intravenous rtPA
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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
Role of Other Fibrinolytic Agents
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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.
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emmedonline
Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor