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GUIDELINES FOR USE OF ALTEPLASE (t-PA) IN ACUTE ISCHEMIC STROKE
Counseling Patients
Major inclusion criteria
Screening of NIHSS score
³
4
Onset (based on the time patient was last known to be normal) well established to be < 3 hours before treatment starts
CT: no hemorrhage or early stroke changes per radiologist or neurologist
Consent of patient and/or next of kin obtained by neurologist
Exclusion criteria
No repeated SBP > 185 mm Hg or DBP > 110 mm Hg at initiation of t-PA
No need for aggressive treatment (IV drip) to reduce BP to specified limits
No capillary blood glucose or serum glucose level < 50 or > 400
No rapidly improving neuro symptoms/signs or only minor symptoms/signs
No seizure at onset
No stroke within prior 3 months
No history of head trauma within 3 months
No lumbar puncture within 24 hours
No major surgery within 14 days
No history of intracranial hemorrhage
No history of intracranial neoplasm, arteriovenous malformation, or aneurysm
No suspicion of subarachnoid hemorrhage despite normal CT
No gastrointestinal or genitouinary hemorrhage within 21 days
No arterial puncture at a noncompressible site within 7 days
No known bleeding diathesis, including but not limited to:
- Current use or warfarin with PT > 15 seconds
- Administration of heparin within 48 hours and elevated aPTT at presentation
Treatment
t-PA 0.9mg/kg (maximum 90mg)
Give 10% as bolus
Give remaining 90% as constant infusion over 60 minutes; start without interruption
Follow-up
General patient management guidelines and other therapy
Admission to ICU for 36 hours
No IV heparin or antiplatelet drugs during the infusion or for 24 hours following onset of symptoms
Neuro checks with vital signs every 30 minutes for 6 hours, then every 1 hour for 18 hours
Cardiac monitoring
Appropriate measures to control BP within acceptable limits
Avoid nasogastric tube, blood draws, and invasive lines/procedures for 24 hours if possible
Intracerebral hemorrhage (ICH) management guidelines
If clinical suspicion of ICH (eg, neurologic deterioration, new headache, acute hypertension, or nausea/vomiting)
discontinue t-PA infusion if applicable
STAT CT for any neurologic deterioration
STAT laboratory: INR, aPTT, platelet count, fibrinogen, and type and cross
Prepare for administration of 6 to 8 units of cyroprecipitated fibrinogen and factor VIII
Prepare for administration of 6 to 8 units of platelets
Reference: Lutsep, H.L., Clark W.M, Acute stroke therapy: perspectives on current, future treatments, Formulary 1997;32: 1040-1055
