Indications for Thrombolytic Therapy for Acute Stroke

Chattanooga area hospitals now offer two different protocols for thrombolytic therapy administered to acute stroke patients.

1) Patients with stroke symptoms of 3 hours or less are evaluated emergently as possible candidates for intravenous t-PA. Click here for a current list of inclusion and exclusion criteria for intravenous tPA. Emergency stroke teams equipped to evaluate and treat patients with intravenous t-PA are available at Memorial, Parkridge, and Erlanger Hospitals.

2) Stroke victims whose onset of symptoms is 6 hours or less are evaluated emergently as possible candidates for intra-arterial t-PA. The inclusion and exclusion criteria for intra-arterial t-PA is similar to that used for intravenous t-PA except patients who are much older, who have very large strokes, or have a INR up to 1.7 may still be considered for intra-arterial t-PA.

3) Referral may also be given to patients with symptoms greater than 6 hours. Patients with symptoms less than 12 hours may be a candidate for one of the ongoing "neuroprotective" clinical trials which may also benefit the patient.

4) Stroke victims who are not candidates for either thrombolytic therapy or a neuroprotective trial may still enjoy a better outcome as a result of being managed at a center trained in acute stroke medical care and neuro-critical care.

In all cases, The decision regarding which therapeutic route is most appropriate for a patient is made by the attending neurologist. Intra-arterial t-PA is administered by an interventional radiologist at either Memorial or Erlanger Hospitals according to well designed, accepted protocols. Use following links for further information regarding services offered by Memorial Hospital or the Emergency Heart and Stroke Center at Erlanger Hospital.

Current Patient Selection for Intravenous t-PA Therapy

• Patients must be treated within 3 hours of onset of acute ischemic stroke symptoms.
  
• Baseline brain CT is performed to rule out intracerebral or subarachnoid hemorrhage that would contraindicate t-PA (Patients with major early infarction signs on the brain CT scan are excluded, e.g., substantial edema,
  mass effect, or midline shift)
  
• Patients with very severe strokes (e.g., NIH Stroke Scale 22 or greater) may be excluded as their risk of intracerebral bleeding after t-PA is markedly increased. This is up to the discretion of the neurologist and family.
  
• Patients less than 18 or greater than 77 years old may not be good candidates for t-PA although treatment is up to the discretion of the neurologist and the patient's family.
  

• More than 3 hours from acute ischemic stroke symptom onset.
  
• Rapidly improving or very minor stroke symptoms.
  
• Intracerebral hemorrhage on current head CT or any history or intracerebral hemorrhage.
  
• Suspicion of subarachnoid hemorrhage based on history despite negative head CT. (These patients typically need a lumbar puncture to definitely rule out SAH and recent lumbar puncture itself is a contraindication for t-PA.)
  
• Recent intracranial surgery or serious head trauma or recent previous stroke (within last 3 months)
  
• Uncontrolled hypertension at time of treatment (e.g., 185 mm Hg systolic or 105 mm Hg diastolic) or need for continuous intravenous infusion of an antihypetensive to bring blood pressure into this range.
  
• Seizure at the onset of stroke. The "stroke symptoms" may be due merely to a post ictal state ("Todd's paralysis") and therefore seizure at the onset of a stroke is a contraindication for tPA
  
• Active internal bleeding (e.g., GI, urinary) within 21 days
  
• Known intracranial neoplasm, atriovenous formation, or aneurysm
  
• Glucose <50 or 400 mg/dL as "stroke symptoms" may resolve when glucose is corrected.
  
• Lumbar puncture within 7 days, major surgery within 14 days
  
• Recent arterial puncture at a noncompressible site
• Acute MI or post-MI pericarditis
  
• Known bleeding diathesis, including but not limited to: