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Management of Acute Ischaemic Stroke (AIS) with Alteplase
- Patients with AIS, regardless of age or stroke severity, in whom treatment can be started within 3 hours of known onset should be considered for treatment with
alteplase.
- Patients with AIS under the age of 80 years in whom treatment can be started between 3 and 4.5 hours of known onset should be considered for treatment with
alteplase.
- Patients with AIS over 80 years in whom treatment can be started between 3 and 4.5 hours of known onset should be considered for treatment with alteplase
on an individual basis. In doing so, treating clinicians should recognise that the benefits of treatment are smaller than if treated earlier, but that the risks of a worse outcome, including
death, will on average not be increased.
- Patients with AIS otherwise eligible for treatment with alteplase should have their blood pressure reduced to below 185/110 mmHg before treatment.
- Alteplase should only be administered within a well-organised stroke service with:
- Emergency medical staff, if appropriately trained and supported, should only administer alteplase for the treatment of AIS provided that patients can be subsequently managed on a HASU with appropriate neuroradiological and stroke physician support.
Alteplase
- IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is recommended for selected patients who may be treated within 3 hours of ischemic stroke symptom
onset or patient last known well or at baseline state. Physicians should review the criteria outlined in Table 6 to determine patient eligibility.
- IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is also recommended for selected patients who can be treated within 3 and 4.5 hours of ischemic stroke symptom onset or patient last known well. Physicians should review the criteria outlined in Table 6 determine patient eligibility.
- For otherwise eligible patients with mild stroke presenting in the 3 to 4.5-hour window, treatment with IV alteplase may be reasonable. Treatment risks should be weighed against possible benefits.
- In otherwise eligible patients who have had a previously demonstrated small number (1-10) of CMBs on MRI, administration of IV alteplase is reasonable.
- In otherwise eligible patients who have had a previously demonstrated high burden of CMBs (>10) on MRI, treatment with IV alteplase may be associated with an increased risk of sICH, and the
benefits of treatment are uncertain. Treatment may be reasonable if there is the potential for substantial benefit.
- IV alteplase for adults presenting with an AIS with known sickle cell disease can be beneficial.
- Abciximab should not be administered concurrently with IV alteplase.
- IV alteplase should not be administered to patients who have received a treatment dose of low-molecular-weight heparin (LMWH) within the previous 24 hours.
- The potential risks should be discussed during thrombolysis eligibility deliberation and weighed against the anticipated benefits during decision making.
- Given the extremely low risk of unsuspected abnormal platelet counts or coagulation studies in a population, it is reasonable that urgent IV alteplase treatment not be delayed while waiting for hematologic or coagulation testing if there is no reason to suspect an abnormal test.
- Treating clinicians should be aware that hypoglycemia and hyperglycemia may mimic acute stroke presentations and determine blood glucose levels before IV alteplase initiation. IV alteplase is not indicated for nonvascular conditions.
- Because time from onset of symptoms to treatment has such a powerful impact on outcomes, treatment with IV alteplase should not be delayed to monitor for further improvement.
- In patients undergoing fibrinolytic therapy, physicians should be prepared to treat potential emergent adverse effects, including
bleeding complications and angioedema that may cause partial airway obstruction.
- BP should be maintained <180/105 mm Hg for at least the first 24
hours after IV alteplase treatment
- The risk of antithrombotic therapy within the first 24 hours after treatment with IV alteplase (with or without EVT) is uncertain. Use might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV alteplase is known to provide substantial benefit or withholding such treatment is known to cause substantial risk.
- In patients eligible for IV alteplase, benefit of therapy is time dependent, and treatment should be initiated as quickly as possible.
Management of Acute Ischaemic Stroke (AIS)with Alteplase and Thrombectomy
- Patients with AIS should be considered for combination IV thrombolysis and intra-arterial clot extraction (using stent retriever and/or aspiration techniques) if they have a proximal intracranial large vessel occlusion causing a disabling neurological deficit (NIHSS &ge 6) and the procedure can begin (arterial puncture) within 5 hours of known onset.
- Patients with AIS and a contraindication to IV thrombolysis but not to thrombectomy should be considered for intra-arterial clot extraction (using stent retriever and/or aspiration techniques) if they have a proximal intracranial large vessel occlusion causing a disabling neurological deficit(NIHSS &ge 6) and the procedure can begin (arterial puncture) within 5 hours of known onset.
- Patients with AIS causing a disabling neurological deficit (NIHSS ≥6 ) may be considered for intraarterial clot extraction (using stent retriever and/or aspiration techniques, with prior IV thrombolysis unless contraindicated) beyond an onset-to-arterial puncture time of 5 hours if:
- the large artery occlusion is in the posterior circulation, in which case treatment up to 24 hours after onset may be appropriate;
- a favourable profile on salvageable brain tissue imaging has been proven, in which case treatment up to 12 hours after onset may be appropriate.
- Patients with AIS treated with thrombolysis should be started on an antiplatelet agent after 24 hours unless contraindicated, once significant haemorrhage has been excluded.
- Patients with AIS should be given aspirin 300mg as soon as possible within 24 hours (unless contraindicated):
- orally if they are not dysphagic;
- rectally or by enteral tube if they are dysphagic.
- Thereafter aspirin 300 mg daily should be continued until 2 weeks after the onset of stroke at which time long-term antithrombotic treatment should be initiated. Patients being transferred to care at home before 2 weeks should be started on long-term treatment earlier.
- Patients with AIS reporting previous dyspepsia with an antiplatelet agent should be given a proton pump inhibitor in addition to aspirin.
- Patients with AIS who are allergic to or intolerant of aspirin should be given an alternative antiplatelet agent (e.g. clopidogrel).
- Patients eligible for IV alteplase should receive IV alteplase even if EVTs are being considered.
- In patients under consideration for mechanical thrombectomy, observation after IV alteplase to assess for clinical response should not be performed.
- Patients should receive mechanical thrombectomy with a stent
retriever if they meet all the following criteria: (1) prestroke mRS
score of 0 to 1; (2) causative occlusion of the internal carotid
artery or MCA segment 1 (M1); (3) age =18 years; (4) NIHSS score
of =6; (5) ASPECTS of =6; and (6) treatment can be initiated (groin
puncture) within 6 hours of symptom onset.
- Although the benefits are uncertain, the use of mechanical
thrombectomy with stent retrievers may be reasonable for carefully
selected patients with AIS in whom treatment can be initiated
(groin puncture) within 6 hours of symptom onset and who have
causative occlusion of the MCA segment 2 (M2) or MCA segment 3
(M3) portion of the MCAs.
- Although the benefits are uncertain, the use of mechanical
thrombectomy with stent retrievers may be reasonable for carefully
selected patients with AIS in whom treatment can be initiated
(groin puncture) within 6 hours of symptom onset and who have
causative occlusion of the anterior cerebral arteries, vertebral
arteries, basilar artery, or posterior cerebral arteries.
- Although its benefits are uncertain, the use of mechanical
thrombectomy with stent retrievers may be reasonable for
patients with AIS in whom treatment can be initiated (groin
puncture) within 6 hours of symptom onset and who have
prestroke mRS score >1, ASPECTS <6, or NIHSS score <6, and
causative occlusion of the internal carotid artery (ICA) or proximal
MCA (M1). Additional randomized trial data are needed.
- In selected patients with AIS within 6 to 16 hours of last known
normal who have LVO in the anterior circulation and meet other DAWN
or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended.
- In selected patients with AIS within 6 to 24 hours of last known
normal who have LVO in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable
- The technical goal of the thrombectomy procedure should be reperfusion to a modified Thrombolysis in Cerebral Infarction (mTICI) 2b/3 angiographic result to maximize the probability of a
good functional clinical outcome.
- As with IV alteplase, reduced time from symptom onset to reperfusion with endovascular therapies is highly associated with
better clinical outcomes. To ensure benefit, reperfusion to TICI grade 2b/3 should be achieved as early as possible within the
therapeutic window.
- Use of stent retrievers is indicated in preference to the Mechanical Embolus Removal in Cerebral Ischemia (MERCI) device.
- The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances, but stent retrievers remain the first choice
- The use of a proximal balloon guide catheter or a large-bore
distal-access catheter, rather than a cervical guide catheter
alone, in conjunction with stent retrievers may be beneficial.
Future studies should examine which systems provide the
highest recanalization rates with the lowest risk for nontarget
embolization.
- Use of salvage technical adjuncts including intra-arterial
thrombolysis may be reasonable to achieve mTICI 2b/3
angiographic results
- EVT of tandem occlusions (both extracranial and intracranial
occlusions) at the time of thrombectomy may be reasonable
- It is reasonable to select an anesthetic technique during
endovascular therapy for AIS on the basis of individualized
assessment of patient risk factors, technical performance of the
procedure, and other clinical characteristics. Further randomized
trial data are needed.
- In patients who undergo mechanical thrombectomy, it is
reasonable to maintain the BP =180/105 mm Hg during and for 24
hours after the procedure.
- In patients who undergo mechanical thrombectomy with
successful reperfusion, it might be reasonable to maintain BP at a
level <180/105 mm Hg.