CVA Thrombolysis

1. See Also
   1. CVA Management
   2. Ischemic CVA
2. Indications (Inclusion Criteria)
   1. Age over 18 years
   2. Clinical Diagnosis of acute Ischemic Stroke
   3. CT Head compatible with Ischemic CVA diagnosis
   4. Known time of onset under 3 hours before Thrombolytics
      1. Do not use intravenous tPA beyond 3 hours of symptoms
3. Contraindications (Exclusion Criteria)
   1. Improving or mild neurologic deficit
   2. Seizure at onset
   3. Blood sugar abnormality
      1. Hypoglycemia (<50 mg/dl)
      2. Hyperglycemia (>400 mg/dl)
   4. Head Injury or CVA within 90 days
   5. History of Intracranial Hemorrhage
   6. Suspected Subarachnoid Hemorrhage (SAH)
      1. Hemorrhage on CT Head
      2. History suggests SAH even despite negative Head CT
   7. Hypertension refractory to antihypertensives
      1. Systolic Blood Pressure over 185
      2. Diastolic Blood Pressure over 110
   8. Major surgery in last 14 days
   9. Gastrointestinal hemorrhage in last 21 days
   10. Genitourinary hemorrhage in last 21 days
   11. Puncture of inaccessible artery within 7 days
   12. Coagulation or Platelet abnormalities
4. Protocol: Thrombolysis
   1. t-PA (Alteplase)
      1. Dose: 0.9 mg/kg (maximum 100 mg)
      2. Bolus 10% over first minute
      3. Give Remainder over 1 hour
   2. Manage Blood Pressure aggressively post-Thrombolytic
      1. Keep Systolic Blood Pressure under 185
      2. Keep Diastolic Blood Pressure under 105
   3. Observed in Intensive Care Unit for first 24 hours
   4. Keep blood sugar <200 mg/dl
   5. No other antithrombotic agents given for 24 hours
   6. CT Head at 72 hours
5. Efficacy
   1. Prevents 11-13 Deaths and Disability for 100 patients
   2. References
      1. (1995) N Engl J Med 333:1581
6. Adverse Effects
   1. Intracranial Hemorrhage
      1. Asymptomatic Intracranial Bleeding
         1. Controls: 2.9%
         2. t-PA: 4.5%
      2. Symptomatic Intracranial Bleeding
         1. Controls: 0.6%
         2. t-PA: 6.4%
      3. All Intracranial Bleeding
         1. Controls: 3.5%
         2. t-PA: 10.9%
   2. Hemorrhagic deaths occurred in critically ill
      1. Very poor prognosis prior to t-PA
   3. References
      1. NIH rTPA Trial
7. References
   1. Anderson (1997) Lecture, FP Update, Minneapolis, MN
   2. Lyden (2001) CMEA Medicine Lecture, San Diego
   3. Lyden (1998) CMEA Medicine Lecture, San Diego
   4. Zivin (1999) Neurology 53(1):14-9