Fibrinolytic

• Fibrinolytic (tissue plasminogen activator tPA)
  • Indicated for ischemic stroke
  • Contraindicated in hemorrhagic stroke
  • >80% of strokes are ischemic
  • A head CT can be used to determine whether ischemic or hemorrhagic stroke
• Clinical outcomes are improved for patients given tPA when other exclusions don’t exist
• tPA can be given 3 hours from onset of symptoms or 4.5 hours in special cases
• Goal is to administer within 60 minutes from ED arrival
• Once given, avoid antiplatelet and anticoagulants for 24 hours

Criteria for Fibrinolytic Treatment

Inclusion Criteria

• Diagnosis of ischemic stroke and neurological deficit present
• Onset of symptoms <3 hours before treatment
• Age >18

Exclusion Criteria

• Head trauma or prior stroke within last 3 months
• Symptoms of subarachnoid hemorrhage
• Arterial puncture at noncompressible site in last 7 days
• Blood pressure >185/110 mmHg
• Active bleed on CT scan, suggestive neuro exam
• Platelets <100,000 per microliter (CBC)
• Heparin received within 48 hours
• aPTT greater than upper limit of normal (coags)
• INR >1.7 or prothrombin time >15 seconds (coags)
• Blood glucose <50 mg/dL (fingerstick)
• CT shows multilobar infarction

Exclusions for 4.5-hour tPA administration

• Age >80
• Severe stroke (NIHSS >25)
• Taking oral anticoagulant regardless of INR
• History of diabetes and previous ischemic stroke

Critical Times in Stroke Care

Post Stroke Management

• Patient should be admitted to a critical care unit
• Monitor patient for any neurologic changes
• Give IV fluids to maintain intravascular volume 75-100 ml/hr
• Monitor blood glucose, goal <185
• Allow for permissive hypertension up to 220 systolic
• Seizure prophylaxis is not warranted