Consider the Use Of Thrombolytic Agents for Treatment of Acute Ischemic Stroke
Nirav G. Shah MD
Acute ischemic stroke is the third leading cause of mortality in the United States and, when not fatal, can result in significant morbidity. The most effective way to decrease morbidity is to restore the blood flow to the ischemic area in a timely manner with thrombolytic therapy. Upon presentation to an emergency room, standard procedures such as establishing medical stability, obtaining a thorough history, and performing a physical examination and laboratory testing should be undertaken immediately. A quick diagnosis in the setting of ischemic stroke is associated with a reduction in morbidity. Following these measures, a computed tomography (CT) scan must be performed to differentiate between subarachnoid hemorrhage, intracerebral hemorrhage, and ischemic infarction. Other studies that may need to be performed based on the history of illness include lumbar puncture (encephalitis, subarachnoid hemorrhage), arterial blood gas (hypoxemia), cervical spine x-rays (trauma), magnetic resonance imaging (better anatomic definition), and cerebral arteriography (if considering intra-arterial thrombolysis).
What to Do
The indication for intravenous thrombolysis in the setting of acute ischemic stroke is predicated on the presentation and diagnosis occurring within 3 hours of symptom onset. The mortality benefit was demonstrated by the National Institute of Neurological Disorders and Stroke Recombinant Tissue Plasminogen Activator (tPA) Stroke Study. Tissue-type plasminogen activator is contraindicated in many patients including those with stroke or head trauma in the previous 3 months, a history of myocardial infarction in the previous 3 months, a history of gastrointestinal bleeding in the previous 3 weeks, and a major surgical procedure in the previous 2 weeks (although surgery is not an absolute contraindication). In addition, patients with thrombocytopenia or coagulopathy should be excluded from use of thrombolytic agents. Blood pressure must also be assessed. Patients with a blood pressure greater than 185/110 mm Hg should not receive tPA. The patient can receive a dose of intravenous (IV) 20 mg of labetotol times 2 doses given 10 minutes apart. If the blood pressure decreases below
185/110 mm Hg and remains, the patient can be considered for tPA. The overall benefit demonstrated by use of tPA was significant with close to 50% of patients having complete or near-complete recovery at 3 months and 1 year as compared with less than 30% in the group treated with placebo.
185/110 mm Hg and remains, the patient can be considered for tPA. The overall benefit demonstrated by use of tPA was significant with close to 50% of patients having complete or near-complete recovery at 3 months and 1 year as compared with less than 30% in the group treated with placebo.
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