Acute ischemic stroke
Michael Y. Wang, Andrea L. Strayer, Odette A. Harris, Cathy M. Rosenberg, Praveen V. Mummaneni in Handbook of Neurosurgery, Neurology, and Spinal Medicine for Nurses and Advanced Practice Health Professionals, 2017
The major risk associated with IV-alteplase is bleeding, particularly symptomatic intracranial hemorrhage (sICH). Rates of bleeding complications are low, even in patients whose symptoms were later attributed to stroke mimics such as complicated migraine, seizure, or conversion disorder (Lewandowski et al., 2015). Signs of sICH include the following: Decrease in level of consciousnessDeterioration in neurologic examNew onset of headacheNew-onset nausea and vomitingElevation in blood pressure
Central Venous Catheter Complications
John K. DiBaise, Carol Rees Parrish, Jon S. Thompson in Short Bowel Syndrome Practical Approach to Management, 2017
Blood reflux into the catheter lumen can lead to thrombus formation and occlusion. Appropriate flushing technique minimizes this risk. When flushing a catheter, both clamping under positive pressure and withdrawing the syringe while depressing the plunger and before the syringe is completely emptied lessen the probability of reflux into the catheter [64,66]. Most thrombotic occlusions can be cleared by administering alteplase [64]. Alteplase, a human tissue plasminogen activator, and urokinase are the best studied thrombolytics. Thrombolytics act by binding to fibrin within a thrombus and there convert the entrapped plasminogen to plasmin, which in turn degrades the fibrin matrix of the thrombus. Although the level of evidence generated from studies of thrombolytic therapies for catheter occlusions is limited by the quality of the studies [67], there is clearly a role for these agents in light of the fact that greater morbidity is derived from catheter replacement. Alteplase is typically administered in a dose of 2 mg/2 mL instilled as a 2-mL dose or to 110% of the catheter volume, if less than 2 mL, with a dwell time of 120 minutes. The thrombolytic is then aspirated and the catheter flushed [68].
General Medical Emergencies
Anthony FT Brown, Michael D Cadogan in Emergency Medicine, 2020
Refer the patient to the medical team or stroke unit for admission and definitive management. Give aspirin 300 mg orally daily or via NGT within 48 h, once CT scan has excluded haemorrhage, unless thrombolysis is used (withold for 24 h).Select patients suitable for thrombolysis if symptom onset is less than 4.5 h, there is a measurable and clinically significant deficit on NIH Stroke Scale examination, CT scan excludes haemorrhage or non-vascular cause, and age is over 18 years: NIH Stroke Scale is a 15-item neurologic examination to evaluate and document neurological status, determine appropriate treatment and predict patient outcome.Get senior ED doctor help and carefully follow local thrombolysis guidelines such as ‘Code Stroke’.Give alteplase 0.9 mg/kg up to 90 mg i.v. over 1 h, with 10% as an initial bolus, having excluded absolute contraindications (see Table 2.12) and considered relative contraindications.
Effect of Acute Stroke Care Regionalization on Intravenous Alteplase Use in Two Urban Counties
Published in Prehospital Emergency Care, 2020
Prasanthi Govindarajan, Stephen Shiboski, Barbara Grimes, Lawrence J. Cook, David Ghilarducci, Tong Meng, Amber W. Trickey
Stroke is one of the leading causes of death and long-term disability (1), but timely hospital-based treatments can significantly reduce adverse outcomes (2, 3). One of the proven treatments is the delivery of the clot-dissolving drug, intravenous alteplase, within 3 hours of the time the patient was last seen normal (4, 5). Even though the treatment window for intravenous alteplase extends up to 4.5 hours, faster treatment is associated with lower stroke-related disability. In an effort to minimize the time to treatment and maximize the treatment rate, almost two decades ago, the Brain Attack Coalition recommended establishing primary stroke centers (6). Following this recommendation, the Joint Commission set up a program for hospitals to become certified primary stroke centers. Studies examining the benefits of primary stroke centers reported higher rates of treatment and lower mortality at these centers (7). This led to the concept of regionalization of acute stroke care, analogous to the current cardiac and trauma models of regionalization (8–11).
Acute ischemic stroke management: concepts and controversies.A narrative review
Published in Expert Review of Neurotherapeutics, 2021
Ka Hou Christien Li, Aaron Jesuthasan, Christopher Kui, Ruth Davies, Gary Tse, Gregory Y. H. Lip
The evidence for thrombolysis in patients with stroke first emerged in 1995 through the National Institute of Neurological Disorders and Stroke (NINDS) trial [9]. In 2001, a conditional license for the use of thrombolysis was given by the European Union, which was made permanent following two iconic studies, namely the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) and the European Cooperative Acute Stroke Study (ECASS) III [10,11]. Both studies assessed the safety and efficacy of intravenous alteplase as the mainstay for thrombolytic therapy. SITS-MOST confirmed that in an ischemic stroke, the use of alteplase is effective in routine clinical use when used within 3 hours. This 3-hour threshold was subsequently extended to 4.5 hours after the ECASS trial. Once the onset of ischemic stroke has been established to be less than 4.5 hours, alteplase can be administered at 900 micrograms/kg accordingly. This is a widely accepted approach with alterations according to local hospital guidelines. More recently, the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED) compared a lower dose (600 microgram/kg) alteplase against the standard dose, which showed a lower risk of intracranial hemorrhage, but did not adequately assess if a lower dose regime was of similar efficacy [12].
Making a case for the right ‘-ase’ in acute ischemic stroke: alteplase, tenecteplase, and reteplase
Published in Expert Opinion on Drug Safety, 2019
Katleen Wyatt Chester, Megan Corrigan, J. Megan Schoeffler, Michelle Shah, Florence Toy, Barbara Purdon, George M. Dillon
The most common type of stroke is an acute ischemic stroke (AIS), which accounts for 87% of all strokes [1]. Ischemic stroke is caused by a blood clot or blockage in a cerebral artery that interrupts blood flow to the brain, resulting in neurological dysfunction [4]. The American Heart Association (AHA)/American Stroke Association (ASA) guidelines for the early management of patients with AIS recommend administration of intravenous (IV) alteplase in eligible patients within 4.5 h of symptom onset [5]. Alteplase is a recombinant human tissue plasminogen activator approved by the US Food and Drug Administration (FDA) for the management of AIS [6]. Alteplase binds to fibrin in a thrombus and activates fibrin-bound plasminogen to active plasmin, thereby inducing fibrin degradation and thrombolysis [6]. In clinical trials, patients who received alteplase within 4.5 h after onset of AIS symptoms were more likely to have minimal or no disability as well as improved Barthel Index, modified Rankin Scale, and National Institutes of Health Stroke Scale scores at 3 months compared with those who received placebo [7–9]. Widespread use of alteplase for the treatment of AIS has been limited by concerns of hemorrhagic complications, specifically symptomatic intracerebral hemorrhage [10]. However, the significantly improved outcomes at 3 months in patients with AIS treated with alteplase generally outweigh the risk for hemorrhagic events in these patients [7–9].
Related Knowledge Centers
- Central Venous Catheter
- Hypotension
- Myocardial Infarction
- Endothelium
- Pulmonary Embolism
- Stroke
- Artery
- Tissue-Type Plasminogen Activator
- Thrombolysis
- Intravenous Therapy