Acute ischemic stroke is a serious medical emergency. It is critical to assess and manage acute ischemic stroke patients as soon as they arrive in the emergency department (ED) of the hospital.

Did you know that in 2013, 59.7% of hospitals participating in the American Heart Association/American Stroke Association (AHA/ASA) Get With The Guidelines® registry achieved a door-to-needle time of ≤60 minutes?6

Stroke Treatment Guidelines

AHA/ASA 2013 Guidelines: immediate diagnostic tests for all patients with suspected AIS1

  • Non-contrast brain CT or brain magnetic resonance imaging (MRI)
  • Blood glucose
  • Oxygen saturation
  • Serum electrolytes/renal function tests*
  • Complete blood count, including platelet count*
  • Markers of cardiac ischemia*
  • Prothrombin time (PT)/international normalized ratio (INR)*
  • Activated partial thromboplastin time (aPTT)*
  • Electrocardiogram*

AHA/ASA 2013 Guidelines: additional diagnostic tests for selected patients with suspected AIS1

  • Thrombin time and/or ecarin clotting time if it is suspected the patient is taking direct thrombin inhibitors or direct factor Xa inhibitors
  • Hepatic function tests
  • Toxicology screen
  • Blood alcohol level
  • Pregnancy test
  • Arterial blood gas tests (if hypoxia is suspected)
  • Chest radiography (if lung disease is suspected)
  • Lumbar puncture (if subarachnoid hemorrhage is suspected and CT scan is negative for blood)
  • Electroencephalogram (if seizures are suspected)
  • *Although it is desirable to know the results of these tests before administering tPA, fibrinolytic therapy should not be delayed while awaiting results unless: 1) there is clinical suspicion of a bleeding abnormality or thrombocytopenia, 2) the patient has received heparin or warfarin, or 3) the patient has received other anticoagulants (direct thrombin inhibitors or direct factor Xa inhibitors).
  • AHA=American Heart Association; AIS=acute ischemic stroke; ASA=American Stroke Association; CT=computed tomography; tPA= tissue plasminogen activator.

    Indications

  • Limitation of Use: The risk of stroke may outweigh the benefit produced by thrombolytic therapy in patients whose AMI puts them at low risk for death or heart failure.

    Activase is indicated for the lysis of acute massive pulmonary embolism (PE), defined as:

    • Acute pulmonary emboli obstructing blood flow to a lobe or multiple lung segments.
    • Acute pulmonary emboli accompanied by unstable hemodynamics, e.g., failure to maintain blood pressure without supportive measures.

    Important Safety Information

    Contraindications

    Do not administer Activase to treat acute ischemic stroke in the following situations in which the risk of bleeding is greater than the potential benefit: current intracranial hemorrhage (ICH); subarachnoid hemorrhage; active internal bleeding; recent (within 3 months) intracranial or intraspinal surgery or serious head trauma; presence of intracranial conditions that may increase the risk of bleeding; bleeding diathesis; and current severe uncontrolled hypertension.

    Orolingual Angioedema

    Orolingual angioedema has been observed during and up to 2 hours after infusion. In many cases, patients received concomitant angiotensin-converting enzyme inhibitors. Monitor patients treated with Activase during and for several hours after Activase infusion for orolingual angioedema. If angioedema develops, discontinue the Activase infusion and promptly institute appropriate therapy.

    Cholesterol Embolization

    Cholesterol embolism, sometimes fatal, has been reported rarely in patients treated with thrombolytic agents; the true incidence is unknown. It is associated with invasive vascular procedures and/or anticoagulant therapy.

    Reembolization of Deep Venous Thrombi during Treatment for Acute Massive Pulmonary Embolism

    Activase has not been shown to treat adequately underlying deep vein thrombosis in patients with PE. Consider the possible risk of reembolization due to the lysis of underlying deep venous thrombi in this setting.

    Coagulation Tests May be Unreliable during Activase Therapy

    Coagulation tests and/or measures of fibrinolytic activity may be unreliable during Activase therapy unless specific precautions are taken to prevent in vitro artifacts.

    Adverse Reactions

    The most frequent adverse reaction associated with Activase therapy is bleeding. Source

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