Use of tPA for ischemic stroke

1
Use of t-PA for ischemic stroke

• Jack CF Chong, MD

2
Stroke and t-PA

• NINDS (NEJM)
• RCT (n 312)
• 30 more likely to have minimal or no disability
• 6.4 ICH (0.6 for placebo)
• ECASS-II (Lancet)
• RCT (n 800)
• Cleveland area experience (JAMA)
• Retrospective chart reviews (n 3,948)

3
Stroke and t-PA

• Proven efficacy
• In the hands of experts
• RCT
• Uncertain effectiveness
• In community practice
• Observational studies

4
ACLS Stroke and t-PA

• Drug Alteplase
• Dose 0.9mg/kg, 10 bolus 90 over 60 min
• Hint Do not give aspirin / heparin during the
  first 24 hr of t-PA therapy

5
ACLS Stroke and t-PA

• Inclusion criteria
• Onset lt 3h
• No ICH, no SAH, no mass effect on CT scan
• After neurologist and/or neurosurgeon
  consultation
• NIHSS must not lt 4 or gt 22
• Patient's or family's consent

6
ACLS Stroke and t-PA

• Exclusion criteria (1)
• Variable / rapidly improving neurologic deficits
• Active internal bleeding within 21 days (except
  menses)
• Aortic dissection
• History of CNS tumor
• History of hemorrhagic stroke
• History of ischemic stroke within 1 year

7
ACLS Stroke and t-PA

• Exclusion criteria (2)
• CNS surgery / trauma within 3 months
• Major surgery / trauma within 14 days
• BP gt 185/110 mmHg
• Known bleeding tendency or INR gt 1.7
• Lumbar puncture within 7 days
• Recent arterial puncture at non-compressible site
• Prolonged CPR with thoracic trauma

8
Conclusion

• Use of t-PA for ischemic stroke
• Approved and available therapy
• Standard therapy (?)
• Discuss with patient / family
• Signed, witnessed, informed consent