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Guidelines From the American Heart Association and American Academy of Neurology Regarding Use of t-PA to Treat Ischemic Stroke   9-1999                                                             

Intravenous recombinant t-PA (0.9 mg/kg, max. 90 mg, with 10% of the dose given as a bolus followed by a 60-minute infusion) was recommended for patients who meet all of the following criteria:

• —Onset of ischemic stroke was less than or equal to three hours prior to treatment

• —Diagnosis has been established by physician with expertise in diagnosing stroke

• —CT of the brain confirms diagnosis, and was assessed by physicians with expertise in reading CT images

• —CT does not show evidence of recent major infarction

• —Patient is not currently taking oral anticoagulants

• —Prothrombin time is less than or equal to 15 seconds (INR ratio < 1.7)

• —Patient has not taken heparin in the past 48 hours and does not have a prolonged partial thromboplastin time

• —Platelet count is greater than or equal to 100,000/mm3

• —Patient has no history of prior stroke or serious head injury in the past 3 months

• —Patient has not had major surgery within the past two weeks

• —Pretreatment systolic BP is less than or equal to 185 mm Hg and diastolic BP is less than or equal to 110 mm Hg

• —Patient does not have rapidly improving neurological signs

• —Patient does not have isolated mild neurological deficits
      (e.g., ataxia alone, sensory loss alone, dysarthria alone, or minimal weakness)

• —Patient has no history of intracranial hemorrhage

• —Blood glucose level must be 50 to 400 mg/dL

• —Patient did not experience a seizure at the onset of stroke

• —Patient has not experienced gastrointestinal or urinary bleeding within the past 21 days

• —Patient has no history of recent myocardial infarction

t-PA should not be used more than three hours after stroke onset or when the time of onset cannot reliably be determined

t-PA should be used with caution in patients with severe stroke (NIH Stroke Scale score > 22)

If possible, the risks should be discussed with the patient and family prior to treatment

t-PA should be administered only if emergent ancillary care and the facilities to handle bleeding complications are readily available, including:

• —Admission to a skilled-care facility with close observation, frequent neurological assessment, and
      cardiovascular monitoring

• —Management of arterial blood pressure during and for 24 hours after administration

• —Restriction of central venous access and arterial punctures for 24 hours after treatment

• —Avoidance of indwelling bladder catheter placement during and for 30 minutes after treatment

• —Avoidance of nasogastric tube insertion for 24 hours after treatment

• —CT scan to detect possible bleeding for any patient with neurologic worsening after administration of t-PA
      (until CT scan can be performed, bleeding should be the assumed cause)

• —Management of life-threatening hemorrhagic complications by:

  1. discontinuing ongoing infusion of t-PA,

  2. obtaining blood samples for coagulation testing (hematocrit, hemoglobin, partial thromboplastin time, prothrombin time/International Normalized Ratio, platelet count, fibrinogen) and type/cross matching in case transfusion is needed,

  3. obtaining surgical consultation as needed, and

  4. implementation of other interventions that may be useful (e.g., transfusion, cryoprecipitate, platelets)

After treatment, patients should not be given aspirin, heparin, warfarin, ticlopidine, or other antithrombotic or antiplatelet drugs for at least 24 hours

Intravenous streptokinase is not recommended for use outside of clinical trials in managing acute ischemic stroke

Intra-arterial thrombolysis warrants further study. In the meantime, it should be considered investigational and used only in clinical trials by physicians experienced with neurointervention techniques working in centers with neurological expertise

Sources

Adams HP, Brott TG, Furlan AJ, et al from a Special Writing Group of the Stroke Council, American Heart Association. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. Available at:   www.Americanheart.org

Accessed September 6, 1999.

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