Stroke (CVA - Cerebrovascular Accidents)
See TIA &
Acute t-PA Rx
Initial Medical Management
1. Acute t-PA treatment
within 3 hours of stroke:
A five-year clinical trial has shown that treatment with the clot-dissolving
drug t-PA is an effective emergency treatment for acute ischemic stroke despite
some risk from bleeding. The trial found that carefully selected stroke patients
who received t-PA treatment within 3
hours of their initial stroke symptoms were at least
30 percent more likely than untreated patients to recover from their stroke
with little or no disability after three months. The nationwide study
of more than 600 stroke patients was organized and funded by the National
Institute of Neurological Disorders and Stroke (NINDS). Results appear
in the December
14, 1995, NEJM (abstract) See
** Guidelines from the American Heart Association
& American Academy of Neurology
regarding Use of t-PA to treat Ischemic Stroke - Sep. 6, 1999
Recombinant Tissue-Type Plasminogen Activator (Alteplase) for Ischemic
Stroke 3 to 5 Hours After Symptom Onset
The ATLANTIS Study: A Randomized Controlled Trial
Dec. 1,1999;282:2019-2026 - Wayne M. Clark
This study found no significant rt-PA benefit on the 90-day efficacy end
points in patients treated between 3 and 5 hours. The risk of symptomatic
ICH increased with rt-PA treatment. These results do not support the use
of intravenous rt-PA for stroke treatment beyond 3 hours.
Intra-arterial Prourokinase for Acute Ischemic Stroke
The PROACT II Study: A Randomized Controlled Trial
Dec. 1, 1999;282:2003-2011 - Anthony Furlan
Despite an increased frequency of early symptomatic intracranial hemorrhage,
treatment with IA r-proUK within 6 hours of the onset of acute ischemic stroke
caused by MCA occlusion significantly improved clinical outcome at 90 days.
Thrombolytic Therapy for Acute Ischemic Stroke: Do the Benefits Outweigh
Medical Crossfire Nov.15, 1999:Vol.1.No.10 - Louis R. Caplan, etc.
Intravenous Tissue-Type Plasminogen Activator for Treatment of Acute Stroke
The Standard Treatment with Alteplase to Reverse Stroke (STARS) Study
Gregory W. Albers, etc -
March 1, 2000;283:1145-1150
Use of Tissue-Type Plasminogen Activator for Acute Ischemic Stroke
- The Cleveland Area Experience
Irene L. Katzan, etc. -
March 1, 2000;283:1151-1158
2. Blood Pressure Control.
We encourage the use of antihypertensive agents that work by peripheral action,
are short acting, and are unlikely to drop the blood pressure precipitouslly
for Treatment of Hypertension in Acute Stroke (NINDS 12/1996)
Proceedings of a National Symposium on Rapid Identification and Treatment
of Acute Stroke December 12-13, 1996
Algorithm for Emergency Treatment of Blood Pressure in Patients with Ischemic
Blood pressure obtained by automatic sphygmomanometer should be correlated
with a manual blood pressure cuff reading.
If diastolic blood pressure > 140 mm Hg occurs on two readings 5 minutes
apart, then start a continuous IV infusion of an antihypertensive agent such
as sodium nitroprusside (0.5-1.0 mg/kg/min). Patients who fall into this
category are not candidates for t-PA therapy even if other inclusion criteria
If systolic blood pressure is > 220 mm Hg or diastolic blood pressure
is 121-140 mm Hg or mean arterial blood pressure is > 130 mm Hg on two
readings 20 minutes apart, then give an easily titratable antihypertensive
medication such as labetalol at 10 mg IV over 1-2 minutes. The labetalol
dose may be repeated or doubled every 10-20 minutes until a cumulative dose
of 300 mg has been administered via this mini-bolus technique. After the
initial dosing schedule, labetalol doses may be administered every 6-8 hours
as needed. Labetalol is usually avoided in patients with asthma, cardiac
failure, or severe cardiac conduction abnormalities. Enalapril (1.25 mg over
5 minutes and repeated every 6 hours or as needed) is an acceptable alternative,
particularly in patients with congestive heart failure. Consider starting
with 0.625 mg over 5 minutes in the elderly. IV esmolol or small patches
of nitropaste are other options. Patients who require more than two doses
of labetalol or other antihypertensive agents to decrease blood pressure
to < 185 mm Hg systolic or 110 mm Hg diastolic are generally not candidates
for thrombolytic therapy even if other criteria are met.
If systolic blood pressure is 185-220 mm Hg or diastolic blood pressure is
105-120 mm Hg, emergency therapy should be deferred in the absence of left
ventricular failure, aortic dissection, or acute myocardial ischemia. Patients
who are potential candidates for t-PA therapy but who have persistent elevations
in systolic blood pressure of > 185 mm Hg or diastolic pressure of >
110 mm Hg may be treated with small doses of IV antihypertensive medication
to maintain the blood pressure just below these limits. However, more than
two doses of an antihypertensive agent to lower the blood pressure below
these limits is a relative contraindication for thrombolytic therapy and
should be discouraged.
If blood pressure is lowered by antihypertensive agents in the setting of
acute stroke, serial neurological examinations should be performed to look
for signs of deterioration such as increasing weakness or reduced level of
In acute stroke patients with systolic blood pressure < 185 mm Hg or diastolic
blood pressure < 105 mm Hg, antihypertensive therapy is usually not indicated.
Although there are no data to support a threshold for treatment of hypotension
in stroke patients, we recommend treatment for signs of dehydration, blood
pressure that is substantially below the expected level for a given patient
(consider past history of hypertension, treated or untreated), or both.
Therapeutic options should include IV fluids, treatment of congestive heart
failure and bradycardia, and consideration of pressor agents such as dopamine.
Treatment of hypertension in acute stroke:
Lowering BP is contraindicated unless
Mean Arterial Pressure (MAP) is > 120-130
[MAP = DBP + (SBP - DBP)/3 . Normally 85-100
Hypertensive encephalopathy is present , or
Vital organs is compromised
3. Anti-platelet agents
The antiplatelet agents aspirin and ticlopidine are both beneficial in the
prevention of stroke following a TIA .
The combination of aspirin and dipyridamole for stroke prevention in patients
with TIA is not recommended . There is no persuasive evidence of benefit
from dipyridamole (Persantine®), sulfinpyrazone, or suloctidil.
4. Treatment with heparin and
warfarin is not routinely recommended for patients with TIA's
either acutely or as long-term therapy . Anticoagulation therapy is recommended
for patients with TIA who have cardiac disease that is considered likely
to cause embolism (atrial fibrillation, mitral stenosis, prosthetic cardiac
valves, recent myocardial infarct, left ventricular thrombus, atrial myxoma,
dilated cardiomyopathy, marantic (nonbacterial) endocarditis, but not for
those with infective endocarditis without an underlying valvular defect .
Anticoagulation therapy is an option in patients with TIA who continue to
have symptoms despite antiplatelet therapy .
Intravenous heparinization of the patient with crescendo TIA is
of undemonstrated benefit and without demonstrated harm. Management of the
patient regarding this decision is suggested to be made on an individual
Heparing and warfarin have been used to treat some cardiac conditions
based on indirect evidence where the use of these medicines has not been
shown to reduce TIA or stroke risk. These conditions include sick sinus syndrome,
patent foramen ovale, atherosclerotic debris in thoracic aorta, spontaneous
echocardiographic contrast, myocardial infarction longer than 2-6 months
ago, hypokinetic or akinetic left ventricular segment, and calcification
of the mitral annulus.
Treatment of Acute Ischemic Stroke - Thomas Brott, etc
Prevention of a First Stroke: A Review of Guidelines and a Multidisciplinary
Consensus Statement From the National Stroke Association - Philip B.
Clinician Information on Stroke:
Patient Information on Stroke: