The "Golden Hour" of Acute Ischemic Stroke

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Treatment Guidelines & Recommendations - Part II

Early CT Changes in Ischemic Stroke

Loss of insular ribbon
Loss of gray-white interface
Loss of sulci
Acute hypo density
Mass effect
Dense MCA sign

Differential Diagnosis

Intracerebral hemorrhage
Hypoglycemia / Hyperglycemia
Seizure
Migraine headache
Hypertensive crisis
Epidural / Subdural
Meningitis / Encephalitis / Brain abscess
Tumor

What are the Options?

No thrombolytics

Nothing
Aspirin
Heparin

Intravenous rt-PA

Other

Intra-arterial thrombolytics
Low dose IV rt-PA followed by IA rt-PA
Investigation procedure

rt-PA Treatment Based on CT Findings

CT Findings	Recommendations
None Subtle < 1/3 MCA Subtle > 1/3 MCA Hypodensity < 1/3 MCA Hypodensity > 1/3 MCA	Treat Treat Probably treat Probably treat Don’t treat

Exclusions to Thrombolytics

Stroke or head trauma in 3 mos Major surgery within 14 days Any history of intracranial hemorrhage SBP > 185 mm Hg DBP > 110 mm Hg Rapidly improving or minor symptoms Symptoms suggestive of subarachnoid hemorrhage Glucose < 50 or > 400 mg/dl	GI hemorrhage within 21 days Urinary tract hemorrhage within 21 days Arterial puncture at non-compressible site past 7 days Seizures at the onset of stroke Patients taking oral anticoagulants Heparin within 48 hours AND an elevated PTT PT >15 / INR >1.4 Platelet count <100 X 10/L
“Patients were also excluded if aggressive measures were required to lower the blood pressure to within specified limits”

Pretreatment BP Treatment

“Gentle” management if thrombolytic candidate:

SBP > 180 mm Hg
DBP > 110 mm Hg

Choices:

Labetalol 10 - 20 mg IV
Enalapril 1.25 mg IV
Nitropaste 1” to chest wall

No nipride or nitroglycerin gtts

Treatment Considerations: Who will benefit from rt-PA?

Patient age and past medical history (diabetes)
Time from onset
Blood pressure
Stroke severity
Stroke subtype
CT findings

Factors Associated with Increased Risk of ICH

Treatment initiated > 3 hours
Increased thrombolytic dose
Elevated blood pressure
NIHSS > 20 *
Acute hypodensity or mass effect *
* Even though increased r/o ICH, still with benefit vs. placebo

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This presentation was written by Dr. Edward C. Jauch of the Greater Cincinnati / Northern Kentucky Stroke Team at the University of Cincinnati College of Medicine.

Last Revised: March 26, 2001

Internet Stroke Center at Washington University:
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