Ischemic Stroke

Links:

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

  • Score with NIH Stroke Scale
  • Image with CT Head (non-contrast), unless there is indication for MRI
  • Labs, glucose before tPA, otherwise:
    • CBC, CMP, Coags, Troponin, EKG, CXR
  • tPA!?! 0.9mg/kg IV, first 10% bolus in 1 minute and remaining dose over 60 mins.

Indications for Alteplase (Inclusion Criteria)

  • Clinical Diagnosis of Ischemic stroke causing a measurable neurological deficit.
  • Typically viewed to be a National Institute of Health Stroke Scale (NIHSS) ≥4 although any disabling deficit should be considered
  • Time of symptom onset established within 3 hours of Alteplase administration.
  • Select patients may be eligible to receive Alteplase between 3 and 4.5 hours from symptom onset.

Contraindications to Alteplase (Exclusion Criteria)

Absolute contraindications:

  • Evidence of intracranial hemorrhage on CT scan
  • Suspicion of subarachnoid hemorrhage based on clinical presentation
  • History of intracranial hemorrhage
  • Uncontrolled hypertension at the time of treatment (SBP>185, DPB>110) Note; IV antihypertensives agents (Labetalol preferred) may be used to lower blood pressure to an acceptable level prior to tPA infusion.
  • Blood glucose concentration < 50 mg/dL and >400 mg/dL. Note an attempt should be made to correct the blood glucose and the patient should be reassessed for ongoing neurological deficits. If the glucose is corrected and the disabling neurological symptoms persist, Alteplase should be considered.
  • Any active bleeding
  • Any intracranial/intraspinal surgery, serious head trauma or previous stroke with in the past 3 months.
  • History of intracranial neoplasm, arteriovenous malformation or aneurysm
  • Acute bleeding diathesis, including but not limited to:
  • Current use of oral anticoagulants with PT.> 15 sec or INR >1.7
  • Patients taking direct thrombin inhibitors and direct Factor Xa inhibitors.
  • Administration of heparin within 48 hours and an elevated PTT at presentation greater than upper limits of normal.
  • Platelet count <100,000/mm3 (Patients transfused platelets can be reconsidered)
  • Arterial puncture at a noncompressible site in previous 7 days
  • CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
  • Use of low molecular weight heparin within the past 12 hours
  • Infective endocarditis

Relative Contraindications: risk of intracranial (Use caution) hemorrhage may be increased in the conditions listed below: In these situations, anticipated benefits should be weighed against the potential risk.

  • Patients with minor (non-disabling) or rapidly improving stroke symptoms,
  • Pregnancy,
  • Seizure at symptom onset,
  • Lumbar puncture within 48 hours,
  • Patients with a INR between 1.4.- 1.7
  • Patients with recent myocardial infarction within 3 months,
  • Major surgery or serious trauma within 14 days
  • Recent gastrointestinal or urinary tract hemorrhage within 21 days
  • Arterial puncture at a noncompressible site in previous 7 days
  • Additional exclusion criteria for treating patients between 3 and 4.5 hours from symptom onset.
  • Age > 80
  • Use of oral anticoagulants, including direct thrombin inhibitors and Xa inhibitors, regardless of the INR level.
  • NIHSS greater than 25

Endovascular treatment of Ischemic Stroke!?! Consider if NIHSS is > 6.

  • All patients eligible for tPA should receive tPA, even if being considered for endovascular treatment
  • Endovascular treatments (esp. with stent retriever) may be effective in patients presenting within 6 hours of symptoms.

Blood Pressure in Ischemic Stroke

  • Hypertension common in ischemic stroke – attempted mechanism to perfuse ischemic areas
  • BP goals dependent of whether tPA is administered or not, and co-morbid conditions present
  • if tPA contraindicated
    • permissive HTN < 220/120 for initial 24 hours unless evidence of other hypertensive emergency
    • if elevated above 220/120 – lower BP by 15% during 1st 24 hours
  • if administering tPA
    • BP must be < 185/110  before administration and must be maintained < 180/105 for initial 24 hours POST administration to decrease risk of ICH BP q15min x 2hrs; then q30min x 6hrs; then q1hr x 16hrs
  • Choice of Anti-HTN for tPA candidates
    • Labetolol 10-20mg IV over 1-2 min or Nicardipine 5mg/h IV (titrate up 2.5mg/h every 5-15 min to max of 16mg/h)
    • Others may include hydralazine, enalaprilat, esmolol, nitroprusside etc
  • Other Management
    • Antiplatelet ► Aspirin within 48 hours of stroke + Statin
    • Further imaging considerations: CT/MRI/MRA with contrast, TTE, Carotid Dopplers, EEG
    • Patients are at risk for cerebral edema (see treatment of cerebral edema and increased ICP)
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