Imaging seconds; current use of direct thrombin

Imagingthe intracranial vasculature also offers essential information to guide therapy,while imaging the extracranial vasculature can help to inform the mechanism ofthe stroke (and guide interventions to prevent a recurrence). Computedtomography angiography (CTA) or magnetic resonance angiography (MRA) may beused for both intracranial and extracranial imaging. The latter of these, MRA,is obtained in conjunction with brain MRI. Intracranial vasculature imaging isrecommended for patients in to help identify contraindications to fibrinolytictherapy. Carotid ultrasound is useful for imaging of the carotid bifurcation,as well as to assess blood velocities through the carotid artery.


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Initiating therapy

Thrombolytic (fibrinolytic) therapyForpatients diagnosed with ischemic stroke who meet the eligibility criteria,MC2 rapid administration of intravenous recombinant tissue-type plasminogenactivator (r-tPA) within 3 hours after the last known symptom-free time isconsidered optimal (with a goal door-to-needle time ofunder 60 minutes)            .MC3 MC4 Additionally, for a select group of patients administration of an intravenousr-tPA may be given up to 4.5 hours MC5 aftersymptom onset. The eligibility criteria for patients treated within3 hours and within 4.5 hours are  providedin Table 12-3.LMC6 Table 12-3.Eligibility Criteria forIntravenous  r-tPA Administration in Patients with AcuteStroke   Inclusion criteria Absolute Exclusion criteria Relative Exclusion criteria* Patients with acute ischemic stroke who can be treated within 3 hours after symptom onsetLMC7  ·         Ischemic stroke diagnosis with measurable neurological deficit ·         Symptom onset within 3 prior hours ·         Adult (age 18 years or older) ·         Significant head trauma or prior stroke within <3 months prior ·         Subarachnoid hemorrhage suggested by symptoms ·         Arterial puncture at noncompressible site within <7 days prior ·         Prior intracranial hemorrhage ·         Known intracranial neoplasm, arteriovenous malformation, or aneurysm ·         Recent intracranial or intraspinal surgery ·         Hypertension (systolic >185 mm Hg or diastolic >110 mm Hg) ·         Active internal bleeding ·         Tendency for acute bleeding, including but not limited to a low platelet count (<100 000/mm³); heparin received within 48 hours, resulting in abnormally elevated aPTT; current use of anticoagulant with INR >1.

7 or PT >15 seconds; current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa activity assays) ·         Low blood glucose concentration (<50 mg/dL or 2.7 mmol/L) ·         Multilobar infarction revealed by CT ·         Minor or rapidly improving stroke symptoms (clearing spontaneously) ·         Pregnancy ·         Seizure at onset ·         Major surgery or serious trauma within <14 days prior ·         Recent gastrointestinal or urinary tract hemorrhage within <21 days prior ·         Recent acute myocardial infarction within <3 months prior Patients with acute ischemic stroke who can be treated within 3 to 4.5 hours after symptom onsetLMC8  ·         Ischemic stroke diagnosis with measurable neurological deficit ·         Symptom onset within 3 to 4.5 prior hours None given ·         Elderly (age over 80 years) ·         Severe stroke (NIHSS>25) ·         Currently on an oral anticoagulant regardless of international normalized ratio ·         History of both diabetes and prior ischemic stroke *Mounting evidence suggests that under some circumstances, with careful considerationof risk to benefit, patients may receive fibrinolytic therapy despite 1 or morerelative contraindications.  

EndovasculartherapyMC9 Combining intra-arterial fibrinolysis with mechanicalthrombectomy is considered to have the highest rate of recanalization withoutany difference in the rate of intracranial hemorrhage.

Intra-arterialfibrinolysis is considered beneficial for patients with ischemic stroke occurringwithin 6 hours, that are caused by occlusions of the MCA, and who are noteligible for intravenous rtPA. While rtPA carries FDA-approval as anintravenous administration, it is not approved as an intra-arterialadministration. Intra-arterial fibrinolysis should only be performed at aqualified stroke center. Intra-arterial fibrinolysis should not delaymechanical thrombectomy, where stent retrievers (ie, Solitare FR and Trevo) areconsidered preferred over coil retrievers.LMC10 

Antiplatelet therapyAdministration of oral aspirin within the first 24 to 48 hoursof onset of stroke symptoms is recommended for most patients. However, itshould not replace nor delay treatment with an intravenous rtPA.

The use ofother antiplatelet agents (such as clopidogrel, tirofiban, and eptifibatide) isnot established in this setting.LMC11 

Stroke Unit CareMC12 BP13 Within 3 hours of arriving at the facility,the patient should be admitted to a monitored bed on a dedicated stroke unit orintensive care unit (ICU).  Care at thisstage includes monitoring for complications of the stroke and its treatment;controlling blood glucose levels and hypertension, and supporting the ABCs.LMC14 MC15 BP16  If the patient’s neurological condition deteriorates, urgent clinicalassessment and further brain imaging should be considered.

It may be useful toperform repeat brain imaging approximately 24 hours after reperfusion therapyto identify hemorrhagic transformation and to determine the extent ofinfarction, both of which are important when making decisions aboutantithrombotic therapy and deep vein thrombosis (DVT) prophylaxis.   LMC1Jauch2013/p884 col1 para4; p884 col2 para1,3; p885 col2 para1,2; p887 col2 para5ETHOS: Please explain what these eligibility criteriaare and also any other risk stratification that has to take place beforeinitiating fibrinolytic therapy. MC2Addressed – added in table (LMC)Ethos, I think we might need to provide a little moredetail about the medical history, physical exam, and diagnostic tests duringthe initial evaluation of the stroke patient. If possible, please specify whois responsible for obtaining the history and conducting the physical (the ERdoc or neurologist?).

Also, please highlight key information that should beelicited as part of the history/PE, including info that can help identifystroke mimics (and what those stroke mimics are). http://stroke.ahajournals.

org/content/44/3/870.long MC3Addressed – this was addedabove (LMC)Is this the same as rTPA? Is one term preferred overthe other? MC4Addressed – edited text (LMC)ETHOS: Please explain under what conditions theextended timeframe to 4.5 hours would be acceptable. MC5Addressed – added in table (LMC) LMC6Jauch2013/p898 col1 para2-4 LMC7Jauch2013/p898 col2 Table10 LMC8Jauch2013/p899 col1 Table11ETHOS: I think we should mention the possibility ofintra-arterial fibrinolysis. MC9 LMC10 LMC10Jauch2013/p904 col1 para3,5; p904 col2 para1,3,4,6 LMC11Jauch2013/p908 col2 para4-7Bob, I deleted the information about rehabilitation andpalliative care because I think this goes beyond the scope of ACLS. OK? MC12That is correct, good call Melanie BP13 LMC14Jauch2013/p878 col2 Table5; p879 col1 para2; p881 col1 Table8Bob/ETHOS: OK as added? AHA states that managinghypertension is “controversial” so maybe we need more detail aroundthat? MC15That is true about the management of hypertension. Eachneurologist has their own way of managing these patients.

I would mentionstroke unit care, but it is up to them how they manage hypertension with  a stroke. BP16