Thrombolysis For Ischemic Stroke

From Anvita Health Wiki

Contents 1 Epidemiology 2 Indications 3 Contraindications 4 Procedure 5 Radiology 6 Complications 7 Management 8 Notes 9 More General Terms 10 Additional Terms 11 References

Epidemiology

• underutilized
• administered to only 1.12% of ischemic stroke hospitalizations 1999-2004 [5]

Indications

• ischemic stroke with onset within 3 hours

• the window may be extended to 4.5 hours, unless: [6,7]

• older than 80 years
• taking oral anticoagulants ( warfarin)
• NIH stroke scale score > 25
• history of both stroke & diabetes

• no benefit of alteplase if given > 4.5 hours after stroke [10]

• neurological deficit measurable deficit on NIH Stroke scale (> minimal weakness, isolated ataxia, isolated sensory loss or isolated dysarthria)

Contraindications

• historical

• stroke or serious head trauma within the last 6 months
• major surgery or serious trauma within the past 14 days
• history of intra- cranial hemorrhage, AV malformation or aneurysm
• GI or urinary tract hemorrhage within the previous 21 days
• arterial puncture at a non-compressible site within the previous 7 days
• lumbar puncture within the previous 7 days
• recent myocardial infarction-induced pericarditis
• patient on anticoagulation therapy

• clinical

• rapidly improving neurologic signs
• minor symptoms
• systolic blood pressure (BP) > 185 mm Hg
• diastolic BP > 110 mm Hg
• mean arterial pressure > 130 mm Hg
• aggressive BP management needed to control BP
• seizure at onset of stroke
• symptoms suggestive of subarachnoid hemorrhage

• laboratory

• PT > 15 seconds, INR > 1.7
• elevation of PTT in a patient who has received heparin within 48 hours of stroke onset
• platelet count < 100,000/ mm3
• serum glucose < 50 mg/dL or > 400 mg/dL
• women of child-bearing age with a positive pregnancy test

• patient & family do not understand potential benefits & risks
• prior ischemic stroke & diabetes appear not to be contraindications [11]

Procedure

• Administration:

• tissue plasminogen activator ( tPA) 0.9 mg/kg, max 90 mg
• administer 10% of tPA as a bolus
• administer remaining 90% of tPA as an infusion over 1 hour
• ultrasound applied to lesion may enhance recanalization [3]

• Precautions:

• do not give anticoagulants for 24 hours from start of tPA administration
• do not give antiplatelet agents for 24 hours from start of tPA administration
• admit to intensive care unit or acute stroke unit
• maintain systolic BP < 180 mm Hg & diastolic BP < 105 mm Hg
• delay central venous line placement or arterial puncture for 24 hours
• delay inserting indwelling bladder ( foley) catheter for > 30 minutes after tPA administration
• delay ( NG) tube placement for 24 hours

Radiology

• CT scan

• no evidence of intracranial hemorrhage
• no early signs of major hemispheric infarct

• edema, mass effect, sulcal effacement
• if present re-evaluate time of onset 3 presence of these signs may be associated

• no evidence of prior stroke

Complications

• symptomatic intracerebral hemorrhage

• incidence may be slightly higher in patients > 80 years of age [12]

Management

• Blood pressure (BP) management:

• monitor BP for 24 hours after starting tPA administration

• every 15 min for 2 hours
• every 30 min for 6 hours
• hourly for remaining 16 hours
• blood pressure should be maintained below 180 mm Hg systolic & 105 mm Hg diastolic for at least the 1st 24 hours post thrombolysis [8]

• when an acute rise in blood pressure is observed

• consider intracerebral hemorrhage
• stop tPA infusion
• obtain head CT

• systolic BP 180-230 or diastolic BP 105-120 (rechecked)

• labetolol 10 mg IV, over 1-2 min
• monitor every 10 min
• repeat 10-20 mg IV every 10-20 min PRN up to 150 mg
• avoid hypotension

• systolic BP > 230 mm Hg or diastolic BP 121-140 mm Hg

• labetolol 10 mg IV, over 1-2 min q 10 min up to 150 mg
• if response in inadequate, use sodium nitroprusside

• diastolic BP > 140 mm Hg

• nitroprusside 0.5-10 ug/kg/min
• monitor closely
• avoid hypotension

• Post procedure:

• aspirin or clopidogrel 24 hours after thrombolysis [8]

Notes

• tPA is apparently safe if used in patients with stroke mimetic [9]
• outcomes generally better in younger patients [15]

More General Terms

• thrombolytic therapy

Additional Terms

• labetalol (Trandate, Normodyne, Ibidomide, Dilevolol)
• nitroprusside or nitroferricyanide (Nipride, Nitropress [sodium salt])

References

1. Contributions from Thomas Nowak, Dept of Neurosurgery, UCSF Fresno
2. Saver JL & Starkman S State of the art medical management of acute ischemic stroke. State of the art medical management of acute ischemic stroke. PMID: [1]
3. Journal Watch 24(24):183-84, 2004 Alexandrov AV, Molina CA, Grotta JC, Garami Z, Ford SR, Alvarez-Sabin J, Montaner J, Saqqur M, Demchuk AM, Moye LA, Hill MD, Wojner AW; CLOTBUST Investigators. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med. 2004 Nov 18;351(21):2170-8. PMID: [2]
4. Wahlgren N, Ahmed N, Davalos A, Ford GA, Grond M, Hacke W, Hennerici MG, Kaste M, Kuelkens S, Larrue V, Lees KR, Roine RO, Soinne L, Toni D, Vanhooren G; SITS-MOST investigators. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007 Jan 27;369(9558):275-82. PMID: [3]
5. Schumacher HC, Bateman BT, Boden-Albala B, Berman MF, Mohr JP, Sacco RL, Pile-Spellman J. Use of thrombolysis in acute ischemic stroke: analysis of the Nationwide Inpatient Sample 1999 to 2004. Ann Emerg Med. 2007 Aug;50(2):99-107. Epub 2007 May 3. PMID: [4]
6. Hacke W et al Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke N Engl J Med. 2008 Sep 25;359(13):1317-29. PMID: [5]
7. del Zoppo GJ et al Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intravenous Tissue Plasminogen Activator A Science Advisory From the American Heart Association/American Stroke Association Stroke 2009 Aug; 40:2945. <PubMed> PMID: [6] <Internet> [7]
8. Medical Knowledge Self Assessment Program (MKSAP) 14, 15 American College of Physicians, Philadelphia 2006, 2009
9. Chernyshev OY et al. Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology 2010 Apr 27; 74:1340
10. Lees KR et al. Time to treatment with intravenous alteplase and outcome in stroke: An updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010 May 15; 375:1695. PMID: [8]
    - Saver JL and Levine SR. Alteplase for ischaemic stroke - Much sooner is much better. Lancet 2010 May 15; 375:1667. PMID: [9]
11. Mishra NK et al. Thrombolysis outcomes in acute ischemic stroke patients with prior stroke and diabetes mellitus. Neurology 2011 Nov 22; 77:1866 PMID: [10]
12. Mishra N, Ahmed N, Andersen G, et al. Thrombolysis in very elderly people: controlled comparison of SITS International Stroke Thrombolysis Registry and Virtual International Stroke Trials Archive. BMJ 2010; 341:c6046 PMID: [11]
13. Toni D et al. Intravenous thrombolysis in young stroke patients: Results from the SITS-ISTR. Neurology 2012 Mar 20; 78:880 PMID: [12]

thrombolysis for ischemic stroke