Stroke fibrinloysis checklist

Inclusion criteria

Exclusion criteria

Elevated BP in stroke

Links

Brief Summary 2007 NICE guideline Alteplase in Stroke

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 asociation Stroke Fibrinolytic checklist

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

Inclusion Criteria (all must apply)

Cincinnati PreHospital Stroke Scale

Facial Droop

Normal
Abnormal

Arm Drift

Normal
Abnormal (+/- pronator drift)

Abnormal Speech "you can’t teach an old dog new tricks"

Normal – correct words no slurring
Abnormal - slur words, wrong words, unable to speak

Interpretation:

Any 1 of 3 signs is abnormal = 72% probability of stroke

Age 18 years or older?
Clinical diagnosis of ischemic stroke with a measurable neurologic 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 hemorrhage on pretreatment noncontrast head CT?
Clinical presentation suggestive of subarachnoid hemorrhage even with normal CT?
CT shows multilobar infarction (hypodensity greater than one third cerebral hemisphere)?
History of intracranial hemorrhage?
Uncontrolled hypertension: SBP > 185 mm Hg or DBP>110 mm Hg despite repeated measurements? More
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?

Relative Contraindications/Precautions:

Only minor or rapidly improving stroke symptoms (clearing spontaneously)
Within 14 days of major surgery or serious trauma
Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
Recent acute myocardial infarction (within previous 3 months)
Postmyocardial 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.