Rtpa for Acute Ischemic Stroke

From Harrison's Principles of Internal Medicine, 18th Edition

Table 370-1 Administration of Intravenous Recombinant Tissue Plasminogen Activator (Rtpa) for Acute Ischemic Stroke (Ais)a

Indication Contraindication Clinical diagnosis of stroke Onset of symptoms to time of drug administration 3 h CT scan showing no hemorrhage or edema of >1/3 of the MCA territory Age 18 years Consent by patient or surrogate Sustained BP >185/110 mm Hg despite treatment Platelets <100,000; HCT <25%; glucose <50 or >400 mg/dL Use of heparin within 48 h and prolonged PTT, or elevated INR Rapidly improving symptoms Prior stroke or head injury within 3 months; prior intracranial hemorrhage Major surgery in preceding 14 days Minor stroke symptoms Gastrointestinal bleeding in preceding 21 days Recent myocardial infarction Coma or stupor Administration of rtPA  Intravenous access with two peripheral IV lines (avoid arterial or central line placement) Review eligibility for rtPA Administer 0.9 mg/kg IV (maximum 90 mg) IV as 10% of total dose by bolus, followed by remainder of total dose over 1 h Frequent cuff blood pressure monitoring No other antithrombotic treatment for 24 h For decline in neurologic status or uncontrolled blood pressure, stop infusion, give cryoprecipitate, and reimage brain emergently Avoid urethral catheterization for 2 h

aSee Activase (tissue plasminogen activator) package insert for complete list of contraindications and dosing. Abbreviations: BP, blood pressure; HCT, hematocrit; INR, international normalized ratio; MCA, middle cerebral artery; PTT, partial thromboplastin time.