Stroke Thrombolysis

Related Subjects: |Acute Stroke Assessment (ROSIER&NIHSS) |Atrial Fibrillation |Atrial Myxoma |Stroke Thrombolysis |Anterior Choroidal Artery Ischaemic Stroke |Causes of Stroke |Ischaemic Stroke |Cancer and Stroke |Hypertension |Small Vessel Disease |CADASIL |CARASIL

⏱️ Time is brain! IV thrombolysis should be delivered as fast and safely as possible in eligible patients with acute ischaemic stroke.

🧾 Clinical Checklist – All Must Be NO to Thrombolyse

• ❌ Comatose
• ❌ Rapidly resolving symptoms (TIA)
• ❌ Suspicion of alternative pathology (e.g., tumour, septic embolus)
• ❌ Uncontrolled hypertension >185/110 mmHg despite treatment
• ❌ NIHSS <4 or ≥25 (caution if >22)
• ❌ Fixed head/eye deviation

🚫 Exclusion Criteria

• Seizure at stroke onset
• Symptoms of SAH even if CT normal
• Arterial puncture (non-compressible) or LP within 7 days
• Recent CPR (traumatic) within 10 days
• Major surgery/biopsy within 4 weeks
• Recent significant bleeding
• Pregnancy, childbirth (<4 weeks) or breastfeeding (unless consent to pause)
• Head injury within 3 months
• Ischaemic stroke within 3 months / any previous ICH
• Severe liver disease (cirrhosis, portal HTN, hepatitis)
• Active neoplasm with bleeding risk
• Anticoagulation: INR >1.4, APTT prolonged, heparin within 48 hrs

🖥️ CT Criteria – All Must Be NO

• Hypodensity/sulcal effacement >⅓ MCA territory
• Evidence of haemorrhage, tumour, abscess, established infarct
• AVM or aneurysm
• Old infarct + diabetes
• Note: Hyperdense artery sign is NOT a contraindication

✅ Inclusion Criteria – All Must Be YES

• CT normal or consistent with acute ischaemic stroke
• Thrombolysis <3 hrs if >80 yrs; <4.5 hrs if <80 yrs
• Pre-stroke: independent in ADLs
• Consent (verbal or written, or next-of-kin assent)

🧪 Lab Criteria – All Must Be NO

• Glucose <3 mmol/L or >22 mmol/L
• Platelets <100 x 10⁹/L
• Hb <100 g/L or Hct <25%
• INR >1.4 / APTT >36 sec

💉 Alteplase Protocol

• 0.9 mg/kg (max 90 mg)
• 10% IV bolus over 2 mins → 90% infusion over 60 mins
• Continuous monitoring during & 24 hrs post-infusion

📋 First 24 Hours Post-Thrombolysis

• ❌ No NG tubes, urinary catheters, or central lines unless essential
• ❌ No IM injections
• ❌ Avoid anticoagulants & NSAIDs
• ✔️ Use paracetamol for pain/pyrexia

🩺 BP Management

• Pre-treatment: keep BP <185/110 mmHg (IV labetalol or GTN paste)
• Monitor: q15 mins (first 2 hrs), q30 mins (next 6 hrs), hourly (next 18 hrs)
• If persistent HTN: labetalol infusion or sodium nitroprusside

⚠️ Complications

• Anaphylaxis: Stop alteplase → Adrenaline IM 0.5-1 mL, hydrocortisone, chlorpheniramine. Call anaesthetics if airway compromised.
• Life-threatening bleeding: Fluids, cryoprecipitate, FFP, platelets (if prior antiplatelets).
• Suspect ICH if: ↓ GCS, headache, seizure, acute HTN, worsening neuro signs → Stop infusion, urgent CT, contact neurology.

📖 Reference

• AHA Guidelines for Early Management of Acute Ischaemic Stroke (2019 Update)

Cases - Stroke Thrombolysis

• Case 1 - Classic anterior circulation stroke 🧠: A 68-year-old man presents with sudden right-sided weakness and expressive dysphasia. Onset: 90 minutes ago. CT head: no haemorrhage. NIHSS score: 14. Diagnosis: acute ischaemic stroke within 4.5-hour window. Managed with IV alteplase (tPA) after contraindications excluded, plus admission to stroke unit.
• Case 2 - Posterior circulation stroke 🚨: A 55-year-old woman presents with sudden vertigo, vomiting, ataxia, and diplopia. Onset: 2.5 hours ago. Exam: nystagmus, left-sided weakness. CT head: no bleed; CT angiogram: basilar artery occlusion. Diagnosis: acute posterior circulation ischaemic stroke. Managed with IV thrombolysis and urgent referral for mechanical thrombectomy.
• Case 3 - Extended window with imaging selection 🕒: A 72-year-old man is found with left hemiparesis on waking. Last known well: 7 hours ago. CT perfusion: small infarct core, large penumbra in right MCA territory. Diagnosis: wake-up stroke with salvageable brain tissue. Managed with IV thrombolysis (per EXTEND trial criteria) and thrombectomy consideration.

Teaching Point 🩺: Thrombolysis with IV alteplase is indicated for acute ischaemic stroke within 4.5 hours of symptom onset (longer if advanced imaging shows salvageable tissue). Key steps: exclude haemorrhage on CT, assess onset time, check contraindications (recent surgery, bleeding, uncontrolled BP). Mechanical thrombectomy is added in large vessel occlusion up to 6–24 hours in selected patients.