ACLS review: Acute Stroke Part 4

CT Scan

·         Should be completed within 25 minutes of the patient's arrival

·         Should be interpreted within 45 minutes of ED arrival

·         More advanced neurologic imaging should not delay initiation of IV rtPA

·         During the first few hours noncontrast CT scan may not indicate signs of brain ischemia

·         If negative for intracerebral hemorrhage, the patient may be a candidate for fibrinolytic therapy

Fibrinolytics Inclusion Criteria

·         Diagnosis of ischemic stroke causing measurable neurologic deficit

·         Onset of symptoms <3 hours before beginning treatment

·         Age ≥18 years

Fibrinolytics 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 (systolic >185 mm Hg or diastolic >110 mm Hg)

·         Evidence of active bleeding on examination

·         Acute bleeding diathesis, including but not limited to

Platelet count <100 000/mm3

Heparin received within 48 hours, resulting in aPTT >upper limit of normal

             Current use of anticoagulant with INR >1.7 or PT >15 seconds

·         Blood glucose concentration <50 mg/dL (2.7 mmol/L)

·         CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Fibrinolytics Relative Exclusion Criteria

·         Only minor or rapidly improving stroke symptoms (clearing spontaneously)

·         Seizure at onset with postictal residual neurologic impairments

·         Major surgery or serious trauma within previous 14 days

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

·         Recent acute myocardial infarction (within previous 3 months)

Note:  Recent experience suggests that under some circumstances—with careful consideration and weighing of risk to benefit—patients may receive fibrinolytic therapy despite 1 or more relative contraindications. Consider risk to benefit of rtPA administration carefully if any of these relative contraindications is present.

Patients From 3 to 4.5 Hours From Symptom Onset Who Could Be Treated With rtPA

Inclusion Criteria

·         Diagnosis of ischemic stroke causing measurable neurologic deficit

·         Onset of symptoms 3 to 4.5 hours before beginning treatment

Exclusion criteria

·         Age >80 years

·         Severe stroke (NIHSS  score >25)

·         Taking an oral anticoagulant regardless of INR

·         History of both diabetes and prior ischemic stroke

Notes:

The checklist includes some FDA-approved indications and contraindications for administration of rtPA for acute ischemic stroke. Recent guideline revisions have modified the original FDA criteria. A physician with expertise in acute stroke care may modify this list

Onset time is either witnessed or last known normal

In patients without recent use of oral anticoagulants or heparin, treatment with rtPA can be initiated before availability of coagulation study results but should be discontinued if INR is >1.7 or PT is elevated by local laboratory standards

Treatment of carefully selected patients with acute ischemic stroke with IV rtPA between 3 and 4.5 hours after onset of symptoms has also been shown to improve clinical outcome, although the degree of clinical benefit is smaller than that achieved with treatment within 3 hours

In patients without history of thrombocytopenia, treatment with rtPA can be initiated before availability of platelet count but should be discontinued if platelet count is <100 000/mm3