Principles Of Management

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Stroke

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Q

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Stroke reperfusion therapy antithrombolylytics indications

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Inclusion criteriaClinical diagnosis of ischemic stroke causing measurable neurologic deficitOnset of symptoms <4.5 hours before beginning treatment; if the exact time of stroke onset is not known, it is defined as the last time the patient was known to be normal or at neurologic baselineAge ≥18 years

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Antithrombotica

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HistoricalIschemic stroke or severe head trauma in the previous three monthsPrevious intracranial hemorrhageIntra-axial intracranial neoplasmGastrointestinal malignancy or hemorrhage in the previous 21 daysIntracranial or intraspinal surgery within the prior three months

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ClinicalSymptoms suggestive of subarachnoid hemorrhagePersistent blood pressure elevation (systolic ≥185 mmHg or diastolic ≥110 mmHg)Active internal bleedingPresentation consistent with infective endocarditisStroke known or suspected to be associated with aortic arch dissectionAcute bleeding diathesis, including but not limited to conditions defined in 'Hematologic'Hematologic

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Head CT scan

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W

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Additional criteria

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Relative exclusions/warnings¶Only minor and isolated neurologic signs or rapidly improving symptomsΔSerum glucose <50 mg/dL (<2.8 mmol/L)◊Serious trauma in the previous 14 days§Major surgery in the previous 14 days¥History of gastrointestinal bleeding (remote) or genitourinary bleeding‡Seizure at the onset of stroke with postictal neurologic impairments†Pregnancy**Arterial puncture at a noncompressible site in the previous seven days¶¶Large (≥10 mm), untreated, unruptured intracranial aneurysm¶¶Untreated intracranial vascular malformation¶¶Additional relative exclusion criteria for treatment from 3 to 4.5 hours from symptom onsetΔΔAge >80 yearsOral anticoagulant use regardless of INRSevere stroke (NIHSS score >25)Combination of both previous ischemic stroke and diabetes mellitus

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ischemic stroke causing a potentially disabling neurologic deficit, we recommend intravenous alteplase therapy when treatment is initiated within 3 hours of clearly defined symptom onset. Patients in this time window should also be evaluated to determine if they are candidates for mechanical thrombectomy.A meta-analysis of individual patient data from randomized controlled trials found that alteplase treatment within 3 hours of stroke onset led to a good outcome for 33 percent, versus 23 percent for control (odds ratio [OR] 1.75, 95% CI 1.35-2.27) [4

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3 to 4.5 hours — For otherwise eligible patients who cannot be treated in less than 3 hours, we suggest (ie, a weak recommendation) intravenous alteplase therapy provided that treatment is initiated within 3 to 4.5 hours of clearly defined symptom onset. Patients in this time window should also be evaluated to determine if they are candidates for mechanical thrombectomy.The benefit of alteplase extends to 4.5 hours. A meta-analysis of individual patient data from randomized controlled trials found that alteplase treatment from 3 to 4.5 hours of stroke onset led to a good outcome for 35 percent, versus 30 percent for control (OR 1.26, 95% CI 1.05-1.51) [4].There are additional exclusion criteria (table 1) for intravenous alteplase in the 3 to 4.5 hour time window (age >80 years old, an NIHSS score >25, a combination of previous stroke and diabetes, and oral anticoagulant use regardless of INR). However, we do not consider these as absolute contraindications to intravenous alteplase (tPA) treatment in the 3 to 4.5 hour time window, given evidence that alteplase is still beneficial in patients who would otherwise be excluded by these criteria [4,57,69,70]. The additional exclusions from 3 to 4.5 hours were made to satisfy safety concerns from the European regulatory agency and were

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4.5 to 6 hours — Patients within 4.5 to 6 hours from stroke symptom onset should not receive intravenous alteplase because harm may exceed benefit, but they should be evaluated to determine if they are candidates for mechanical thrombectomy. A meta-analysis of individual patient data from randomized controlled trials found that for treatment beyond 4.5 hours, the proportion with a good outcome in the alteplase and control groups was 33 and 31 percent (OR 1.15, 95% CI 0.95-1.40) [4].

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to 24 hours — Patients beyond 6 hours from ischemic stroke symptom onset are not eligible for treatment with intravenous alteplase. However, mechanical thrombectomy is an option at specialized stroke centers using imaging-based selection of patients with anterior circulation stroke who have were last known to be normal or at neurologic baseline 6 to 24 hours before treatment. This is discussed in detail separately.

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Beyond 24 hours — Patients beyond 24 hours from ischemic stroke symptom onset are not eligible for treatment with intravenous alteplase or mechanical thrombectomy

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Age 80 years and older — Patients age 80 years or older appear to benefit from intravenous thrombolysis despite a higher mortality rate compared with younger patients. Therefore, we do not consider age to be a contraindication to intravenous alteplase (tPA) treatment for otherwise eligible patients. However, age >80 years is a relative contraindication in the 3- to 4.5-hour time window

Summery

The immediate goal of reperfusion therapy for acute ischemic stroke is to restore blood flow to the regions of brain that are ischemic but not yet infarcted. Intravenous alteplase (tPA) is the mainstay of reperfusion therapy for acute ischemic stroke. Mechanical thrombectomy is indicated for patients with acute ischemic stroke caused by an intracranial large artery occlusion in the proximal anterior circulation. (See 'Treatment options' above.)●Intravenous thrombolytic therapy with alteplase improves functional outcome at three to six months when given within 4.5 hours of ischemic stroke onset. (See 'Alteplase' above.)●All adult patients with a clinical diagnosis of acute ischemic stroke should be rapidly screened for treatment with intravenous thrombolytic therapy. Simultaneously, patients with suspected acute ischemic stroke involving the anterior circulation should be evaluated for mechanical thrombectomy