Stroke & Cerebrovascular Center

Services - Stroke Prevention & Treatment

Acute Stroke Protocol

tPA Patient Information Sheet and Consent Form (PDF)

Guidelines for Use of Intravenous tPA in Acute Ischemic Stroke

LESS than 4.5 hours from initial symptoms

A.  Indications

• New symptomatic ischemic stroke with clearly defined onset AND
• Onset of symptoms to tPA < 4.5 hours AND
• Non-contrast CT showing no intracranial hemorrhage or well-established acute infarct (>1/3 MCA territory) AND
• Patient evaluated by in-house neurology Fellow or Resident and tPA approved by stroke attending (via phone or in person)

B.  Contraindications

• Age < 18
• CT scan findings (intracranial hemorrhage, or major acute infarct signs)
• Suspicion of subarachnoid hemorrhage (even if head CT is negative for hemorrhage)
• Recent (within 3 months) major surgery (discuss with Attending)
• History of intracranial hemorrhage or brain aneurysm or vascular malformation or brain tumor (May consider IV tPA in patients with CNS lesions that have a very low likelihood of hemorrhage, such as small unruptured aneurysms or benign tumors with low vascularity)
• Known bleeding diathesis OR
  1. Current use of oral anticoagulants or INR > 1.7 or PT > 15 seconds
  2. Administration of heparin within 48 hours preceding onset of stroke AND elevated aPTT at time of presentation
  3. Platelets <100,000
  4. Internal hemorrhage (GI hemorrhage, urinary tract hemorrhage) < 3 weeks
• Persistent systolic BP >185 mm Hg or diastolic BP >110 mm Hg despite treatment.
• MI within last 3 months.
• Acute pericarditis

C.  Warnings (risks must be weighted against anticipated benefits)

• Current use of oral anticoagulants with INR > 1.5 or PT > 15 seconds
• Minor neurological deficit or rapidly improving symptoms
• High likelihood of left heart thrombus
• Recent major surgery, GI/GU bleeding, trauma (< 3 weeks)
• Evidence of infarction of > 1/3 of the MCA territory on CT
• Severe neurological deficit (NIH stroke scale score >22)
• Age > 75 (or 80 for 3-4.5 hours)
• Seizure at stroke-onset
• History of IVDA and/or suspicion for endocarditis
• Cocaine-induced stroke
• Tox-screen positive for ETOH, cocaine, opiates, or amphetamines (if available, but should not delay tPA protocol)
• Subacute bacterial endocarditis
• History of hemorrhagic diabetic retinopathy
• Significant hepatic dysfunction with abnormal INR
• Pregnancy
• Sickle cell disease
• Arterial puncture at non-compressible site < 1 week
• Blood sugar < 50 or > 400 mg/dL
• Currently receiving therapeutic anticoagulation with a low molecular weight heparin

D.  Not a contraindication

• Current aspirin, NSAID or antiplatelet drugs (dipyridamole, ticlopidine, clopidogrel)
• History of PUD (not currently active [>3 months]) Stroke Service (5/2010)

E.  For those patients presenting with a suspected stroke to the Emergency Room:

1. EMT/Triage: alert EM-MD and stroke fellow (pager 1620)
2. Patient is transferred/assigned to the Trauma Room or Acute Side
3. EM/MD: ORDER STAT HEAD-CT (non-contrast enhanced) AND STAT NEURO-CONSULT [If NIHSS >10, order STAT CTA for patients who could be candidates to bridge from iv tPA to intra-arterial intervention]
4. RN/MD:
   - Establish 2 IV sites, including stat 18 gauge antecubital IV for CTA, start 0.9% NS at
   100 cc/hr as prehydration in anticipate of CTA, for total 500 cc
   - Cardiac monitor, pulse oximeter, continuous vital signs
   - 12 lead EKG
   - Clinical evaluation for active illicit drug use (toxicology screen) or ETOH intoxication
   - Obtain patient weight early
   - Notify pharmacy early regarding potential tPA, its preparation.
5. STAT Labs: PTT, INR, CBC (without diff.), electrolytes, BUN, creatinine, CK & troponin, glucose, type & hold
6. t-PA is approved by stroke attending
7. Admit to ICU

F.  For those patients with a suspected stroke while hospitalized

1. Activate the Acute Stroke Team (pager 31-1620); Have unit secretary page CCRN (help with IVs, tPA, transport to ICU)
2. Order a stat head-CT (non-contrast enhanced), CTA if NIHSS >4
3. Order stat blood tests: PTT, INR, CBC (without diff.), electrolytes, BUN, creatinine, CK & troponin, glucose, type and hold
4. t-PA approved by stroke attending
5. Transfer patient to ICU
6. RN/MD (as above)
   - Establish 2 IV sites, including stat 18 gauge antecubital for CTA, start 0.9% NS at 80 cc/hour as prehydration in anticipate of CTA
   - Cardiac monitor, pulse oximeter, monitor vital signs
   - If patient is candidate for IA intervention, foley catheter

G.  Once tPA has been started

• Do not perform for 24 hours post tPA unless procedure is life-saving: Arterial or central venous punctures/lines, IM injections, nasogastric tubes, Foley catheters
• Place the patient on anticoagulation precautions until 24 hours after the infusion
• Do not give any antithrombotic drugs (including heparin, warfarin, aspirin, clopidogrel, dipyridamole, ticlopidine, or NSAIDS x 24 hrs)

H.  Administration

• The stroke fellow may utilize a phone consultation with the stroke attending prior to administering IV tPA
• Administer tPA in monitored setting (unit bed or emergency room)
• Mix two 50 mg tPA vials with 50 mL normal saline each --> one mL solution contains one mg tPA for a total of 100mg in 100mL of solution.
• Estimate total body weight (if not measured on admission)
• Calculate TOTAL tPA DOSE: 0.9 mg per kg (not to exceed 90 mg total dose)
  - Give 10% as IV bolus
  - Give other 90% as IV infusion over 60 minutes
• Vital signs and neurochecks at least every 15 min for first 2 hours.
• Treat systolic BP if it rises to >180 mm Hg or diastolic BP >105 mm Hg for more than 15 minutes
• Avoid BP decrease <160/ 85 mm Hg Stroke Service (5/2010)

t-PA Dosing (estimated weight)

Print tPA Dosing Chart (HTML)

Download tPA Dosing Chart (PDF)

If the patient has a significant neurological deficit (ie NIHSS > 10) and CTA demonstrates proximal vessel occlusion, the neurointerventional team should be activated early (pager 2645 or COIL). If the patient does not improve 1 hour after IV tPA administration, a bridging intervention is recommended with mechanical embolectomy or angioplasty/stent.

I.  Monitoring:

1. Admit to ICU and monitor patient in ICU for a minimum of 24 hours, then on a regular hospital floor for 72 hours. A longer period of monitoring may be indicated.
2. Blood pressure monitoring:
   1. During the first 24 hours after tPA, monitor BP:
      - Every 15 minutes for 2 hours after starting the infusion, then
      - Every 30 minutes for 6 hours, then
      - Every 60 minutes until 24 hours after starting treatment
3. If systolic blood pressure is >180 mmHg or if diastolic blood pressure is >105 mmHg for 2 or more readings 5 to 10 minutes apart, the following is recommended:
   1. First tier intervention: Give IV labetalol 10 mg over 1 to 2 minutes. Labetalol may be repeated up to 3 doses every 10 to 20 minutes (doubling doses if needed depending on effect of preceeding dose; eg. 1st dose-10mg, 2nd dose- 20mg, 3rd dose- 40mg, then consider drip)
      - For heart rate<60/minute, use hydralazine 5-20mg intravenous over 1-2 minutes every 20-30 minutes. After second bolus, consider second line intervention.
      - Monitor blood pressure and neurologic exam every 15 minutes during treatment and observe for development of hypotension for all 3 tiers of BP interventions.
   2. Second tier intervention: If 3 doses of labetalol or hydralazine bolus or 30 minutes pass without sufficient BP control, the next step should be a nicardipine drip.
   3. Third tier intervention: If nicardipine drip fails, then the next step should be a labetalol drip.
      **To avoid worsening of cerebral ischemia, DO NOT lower blood pressure below 160/85 with these interventions**
4. Use 0.9% NS only, as needed (avoid hypotonic solutions)
5. Further work-up/interventions as directed by neurology consult

Reviewed July 2010: Carlos Kase, Viken Babikian, Jose Romero, Aleksandra Pikula, Deborah Green, Joseph Burns, Judith Clark, Helena Lau, Feliks Koyfman, Thanh Nguyen 

REFERENCES

Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008;359:1317-29.

The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-7.

Rost NS, Masrur S, Pervez MA, Viswanathan A, Schwamm LH. Unsuspected coagulopathy rarely prevents IV thrombolysis in acute ischemic stroke. Neurology. 2009 Dec 8;73(23):1957-62. Epub 2009 Nov 25.

Gottesman RF, Alt J, Wityk RJ, Llinas RH. Predicting abnormal coagulation in ischemic stroke: Reducing delay in rt-PA use. Neurology 2006;67;1665-1667

Selim M, Kumar S, Fink J, Schlaug G, Caplan LR, Linfante I. Seizure at stroke onset: should it be an absolute contraindication to thrombolysis? Cerebrovasc Dis. 2002;14(1):54-7.

Martin-Schild S, Albright KC, Misra V, Philip M, Barreto AD, Hallevi H, Grotta JC, Savitz SI. Intravenous Tissue Plasminogen Activator in Patients With Cocaine-Associated Acute Ischemic Stroke.  Stroke 2009;40:3635-3637

De Silva DA, Manzano JJ, Chang HM, Wong MC. Reconsidering recent myocardial infarction as a contraindication for IV stroke thrombolysis. Neurology 2011;76:1838-40.

Mishra NK, Ahmed N, Davalos A, et al. Thrombolysis outcomes in acute ischemic stroke patients with prior stroke and diabetes mellitus. Neurology 2011;77;1866

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Medical Information

Medical information contained on this website is designed to be used only for medical and educational reference. It is not intended to be used as a diagnostic decision-making system and must not be used to replace or overrule a physician's judgment or diagnosis.

The responsibility for decisions regarding actual patient care rests solely with the physician treating a patient. While we try to keep the information as accurate as possible, we disclaim any implied warranty or representation about its accuracy, completeness, or appropriateness for a particular purpose.

Please note that our stroke protocols are subject to change without notice and are not intended for use without concurrent consultation with a BMC Acute Stroke Neurologist.