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==Exclusion Criteria==
==Exclusion Criteria==
===Absolute===
===Absolute===
# BP Systolic >185, diastolic >110 (can receive 1-3 doses anti-hypertensive)
# Head trauma or prior stroke in previous 3 months
# PTT >34, PT >15, or INR >1.7
# Symptoms suggestive of SAH
# Platelet count <100,000
# Arterial puncture at noncompressible site in previous 7 days
# Blood Glucose <50 or >400 mg/dl
# History of previous ICH
# Minor stroke or rapidly resolving stroke
# Elevated BP (sys > 185 or dia > 110
# Hemorrhage or edema on non-con head CT
# Active bleeding on exam
# Suspected SAH
# Acute bleeding diathesis:
# Seizure at onset of stroke
## Plt count < 100K
# Heparin treatment during the past 48 hours with an elevated PTT
## PTT > upper limit of normal
# Evidence of acute myocardial infarction
## INR >1.7
# Blood Glucose <50
# CT demonstrates multilobar infarction (hypodensity > 1/3 cerebral hemisphere)


===Relative===
===Relative===
# History of prior intracranial hemorrhage, neoplasm, AVM or aneurysm
* Minor stroke or rapidly improving stroke symptoms
# Major surgery/trauma within <14 days
* Seizure at onset with postictal residual neuro impairments
# Stroke or serious head injury within 3 months
* Major surgery or serious trauma within previous 14 days
# GI/GU bleeding within <21 days
* Acute GI or GU hemorrhage (within previous 21 days)
# Lactation or pregnancy within <30 days
* Acute MI (within previous 3 months)
 
===Additional Per Harbor Neuro===
# AMI or pericarditis (ECG)
# Aggressive treatment needed to control BP
# Lumbar puncture within <7 days
# Occult blood in urine or stool (UA + Guiac)


===ECASS III Exclusion Criteria (if giving tPA between 3-4.5 hours)===
===ECASS III Exclusion Criteria (if giving tPA between 3-4.5 hours)===

Revisión del 06:43 28 mar 2011

Background

  1. Pros:
    1. 30% greater chance of good neurologic outcome at 3 months
    2. Comparable 3-month mortality rate
  2. Cons
    1. Intracranial hemorrhage occurs in ~5% of pts


  • Coag results prior to tx is only required for pts on anticoagulants
  • ...but if history unable to be obtained must wait for coag results prior to starting tx

Inclusion Criteria

  1. Clinical diagnosis of stroke
  2. Clear onset (last witnessed well) <3 hours
  3. Age >18 yrs

Exclusion Criteria

Absolute

  1. Head trauma or prior stroke in previous 3 months
  2. Symptoms suggestive of SAH
  3. Arterial puncture at noncompressible site in previous 7 days
  4. History of previous ICH
  5. Elevated BP (sys > 185 or dia > 110
  6. Active bleeding on exam
  7. Acute bleeding diathesis:
    1. Plt count < 100K
    2. PTT > upper limit of normal
    3. INR >1.7
  8. Blood Glucose <50
  9. CT demonstrates multilobar infarction (hypodensity > 1/3 cerebral hemisphere)

Relative

  • Minor stroke or rapidly improving stroke symptoms
  • Seizure at onset with postictal residual neuro impairments
  • Major surgery or serious trauma within previous 14 days
  • Acute GI or GU hemorrhage (within previous 21 days)
  • Acute MI (within previous 3 months)

ECASS III Exclusion Criteria (if giving tPA between 3-4.5 hours)

  1. Age > 80
  2. Baseline NIHSS > 25
  3. Any oral anticoagulant use
  4. History of prior stroke and DM

Studies Needed

  1. Head CT
  2. CBC
  3. PT/PTT
  4. Glu check
  5. ECG
  6. Icon

tPA Administration

  1. Alteplase 0.9mg/kg IV (max 90mg total)
    1. Load with .09mg/kg (10% of dose) as IV bolus over 1min, followed by 0.81mg/kg (90% of dose) as cont. infusion over 60min
  2. Neuo check Q15min x 2hrs, Q30min x6hrs, Q1hr x 16hrs
  3. Keep BP <180/105
    1. Labetalol 10mg IV followed by continous IV infusion 2-8mg/min OR
    2. Nicardipine IV 5mg/h, titrate up to desired effect by 2.5mg/hr q 5-15min, maximum 15mg/h
    3. If BP not controlled or dia > 140 consider nitroprusside
  4. No anticoatulation/antiplatelets x 24hrs
  5. Stop tPA and consider head CT if pt develops:
    1. Neuro changes
    2. Acute hypertension
    3. Nausea/vomiting

See Also

Neuro: post-tPA Hemmorhage

Source

1/26/06 DONALDSON (adapted from Lampe, Tintinali)

2/20/10 PANI (ACEP/AAN Guidelines--class B recommendations)

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