Stroke fibrinolysis checklist

Background (Summary 2007 NICE guideline)

• Alteplase is recommended for the treatment of acute ischaemic stroke when used by physicians trained and experienced in the management of acute stroke
• Alteplase has a marketing authorisation for the fibrinolytic treatment of acute ischaemic stroke
• Treatment must be started within 4.5 hours of onset of the stroke symptoms and after prior exclusion of intracranial haemorrhage by means of appropriate imaging techniques
• Alteplase is not indicated for the treatment of acute stroke in children aged under 18 years or adults aged over 80 years
• The recommended dose of alteplase for the treatment of acute ischaemic stroke is 0.9 mg alteplase/kg body weight (maximum of 90 mg) [NICE technology appraisal guidance 122 4 ] infused intravenously over 60 minutes, with 10% of the total dose administered as an initial intravenous bolus
• Alteplase manufacturer identified six relevant robust trials (RCTs) of alteplase in the treatment of acute ischaemic stroke (NINDS I and II, n = 624; ATLANTIS A, n = 142; ATLANTIS B, n = 613; ECASS I, n = 620; and ECASS II, n = 814). The manufacturer’s submission draws on evidence from the Cochrane Review (2003), which was an overall meta-analysis of the use of thrombolytics for acute ischaemic stroke. There is a statistically significant difference (odds ratio [OR] 0.64; 95% confidence interval [95% CI] 0.50 to 0.83) favouring treatment with alteplase in terms of the outcome of death or dependency at 3 months
• The incidence of intracranial haemorrhage was increased in patients receiving alteplase

American Heart association Stroke Fibrinolytic checklist

 tPA in Acute Ischaemic Stroke- All boxes must be checked before tPA can be considered.

Inclusion Criteria (all must apply)

• Age 18 years or older?
• Clinical Dx of ischaemic stroke with a measurable neurological deficit?
• Time of symptom onset (when patient was last seen normal) well established as <180 minutes (3 hours) before treatment would begin?

Exclusion Criteria (NONE must apply)

• Evidence of intracranial haemorrhage on pretreatment noncontrast head CT?
• Clinical presentation suggestive of subarachnoid haemorrhage even with normal CT?
• CT shows multilobar infarction (hypodensity greater than one third cerebral hemisphere)?
• History of intracranial haemorrhage?
• Uncontrolled hypertension: SBP > 185 mm Hg or DBP>110 mm Hg despite repeated measurements?
• Known arteriovenous malformation, neoplasm, or aneurysm?
• Witnessed seizure at stroke onset?
• Active internal bleeding or acute trauma (fracture)?
• Acute bleeding diathesis, including:
  • Platelet count <100 000/mm3? 
  • Heparin received within 48 hours
  • Current use of anticoagulant with INR >1.7 or prothrombin time PT >15 seconds?*
• Within 3 months of intracranial or intraspinal surgery, serious head trauma, or previous stroke?
• Arterial puncture at a noncompressible site within past 7 days?
• Only minor or rapidly improving stroke symptoms (clearing spontaneously)
• Within 14 days of major surgery or serious trauma
• Recent gastrointestinal or urinary tract haemorrhage (within previous 21 days)
• Recent acute myocardial infarction (within previous 3 months)
• Post myocardial infarction pericarditis
• Abnormal blood glucose level (<50 or >400 mg/dL [<2.8 or >22.2 mmol/L])*
• In patients without recent use of oral anticoagulants or heparin, treatment with tPA can be initiated before availability of coagulation study results but should be discontinued if the INR is >1.7 or the partial thromboplastin time is elevated by local

Approach to high BP in stroke

Please see Hypertension in Stroke page.

Links

• NICE 2007 [Alteplase in Stroke] . Local copies full guideline (PDF), quick reference (PDF)
• [Cochrane review] of thrombolysis in acute ischaemic stroke
• Stroke Alteplase calculator
• CUH Stroke pathway
• MUH stroke pathway
• TIA
• Approach to Hypertension in Stroke