59 years old Diabetes patient operated earlier for ASD presented with stroke left he Mille his with motor aphasia. I agreed with my most of friends who mentioned Atrial Fibrillation leading to CVA right MCA Infarction as First Admission CT scan and ECG revealed. Some of the patients develop AF after surgery for ASD. She has permanent AF for the past 4-5 years and on oral Anticoagulation earlier acitrom and on NOAC Rivarobaxan 20 mg daily for the one year. However for the past 3 months on irregular Oral Anticoagulation due to her travel to USA and back. She was back from her trip abroad just week back and presented to Tathagat with Sudden onset stroke within 2 Hours after Stroke. According to latest stroke management AHA guidelines and consultation with neurologist Thrombolytics can be given within 4.5 hours but still with risk of hemorrhagic transformation . Patient was given Tenectaplase 30 mg IV bolus. However patient did not improve and her sensorium worsened early morning and repeat CT revealed Hemorrhagic transformation with midline shift. Emergency craniotomy performed to relieve raised ICT. However her GCS score worsened and pupils dilated and fixed. She was declared brain declared brain dead. We could convince educated family and agreed for organ donation and body donation to medical college.
The American Heart Association/American Stroke Association (AHA/ASA) inclusion guidelines for the administration of rt-PA in under 3 hours are as follows :
Diagnosis of ischemic stroke causing measurable neurologic deficit
Neurologic signs not clearing spontaneously
Neurologic signs not minor and isolated
Symptoms not suggestive of subarachnoid hemorrhage
Onset of symptoms less than 3 hours hours before beginning treatment
No head trauma or prior stroke in past 3 months
No MI in prior 3 months
No GI/GU hemorrhage in previous 21 days
No arterial puncture in noncompressible site during prior 7 days
No major surgery in prior 14 days
No history of prior intracranial bleed
Systolic blood pressure under 185 mm Hg, diastolic blood pressure under 110 mm Hg
No evidence of acute trauma or bleeding
Not taking an oral anticoagulant, or if so, INR under 1.7
If taking heparin within 48 hours, a normal activated prothrombin time (aPT)
Platelet count of more than 100,000/μL
Blood glucose greater than 50 mg/dL (2.7 mmol)
No seizure with residual postictal impairments
Computed tomography (CT) scan does not show evidence of multilobar infarction (hypodensity over one-third hemisphere)
The patient and family understand the potential risks and benefits of therapy
In May 2009, and again in March 2013, the AHA/ASA guidelines for the administration of rt-PA following acute stroke were revised to expand the window of treatment from 3 hours to 4.5 hours to provide more patients with an opportunity to receive benefit from this effective therapy. Eligible patients should receive rtPA therapy as soon as possible, ideally within 60 minutes of hospital arrival. IV fibrinolysis can be considered in patients with rapidly improving symptoms, mild stroke deficits, major surgery within the past 3 months, and recent myocardial infarction; risks should be weighed against benefits.
Eligibility criteria for treatment in the 3 to 4.5 hours after acute stroke are similar to those for treatment at earlier time periods, with any 1 of the following additional exclusion criteria:
Patients older than 80 years
All patients taking oral anticoagulants are excluded regardless of the international normalized ratio (INR)
Patients with baseline National Institutes of Health Stroke Scale (NIHSS) score > 25
Patients with a history of stroke and diabetes
Patients with imaging evidence of ischemic damage to more than one third of the middle cerebral artery (MCA) territory
A Scientific Statement from the AHA/ASA, “Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke,” published in 2015, contained recommendations further elucidating the eligibility criteria for rtPA (alteplase) therapy in patients with acute ischemic stroke. Those recommendations included, but were not limited to, the followin:
For otherwise medically eligible patients aged 18 years or older, intravenous alteplase administration within 3 hours is equally recommended for patients under age 80 years and older than age 80 years
For severe stroke symptoms, intravenous alteplase is indicated within 3 hours from symptom onset of ischemic stroke
For patients with mild but disabling stroke symptoms, intravenous alteplase is indicated within 3 hours from symptom onset of ischemic stroke
Intravenous alteplase treatment in the 3- to 4.5-hour time window is recommended for those patients under age 80 years who have no history of both diabetes mellitus and prior stroke, who have a NIHSS score under 25, who are not taking any oral anticoagulants, and who have no imaging evidence of ischemic injury involving more than one third of the middle cerebral artery territory
Intravenous alteplase treatment is reasonable for patients who present with moderate to severe ischemic stroke and demonstrate early improvement but remain moderately impaired and potentially disabled in the judgment of the examiner
The time from last seen normal to treatment with intravenous alteplase should be under 3 hours for eligible patients with the use of standard eligibility criteria
Intravenous alteplase administration is recommended in the setting of early ischemic changes (EICs), seen on CT scan, of mild to moderate extent (other than frank hypodensity)
For EICs on CT scan, administering intravenous alteplase to patients whose CT brain imaging exhibits extensive regions of clear hypoattenuation is not recommended
Intravenous alteplase is reasonable for the treatment of acute ischemic stroke complications of cardiac or cerebral angiographic procedures, depending on the usual eligibility criteria
Intravenous alteplase is recommended for patients taking antiplatelet drug monotherapy before stroke on the basis of evidence that the benefit of alteplase outweighs a possible small increased risk of symptomatic intracerebral hemorrhage (sICH)
Benefits and Risks of Thrombolytics
The chief benefit of thrombolysis is improved final functional outcome through reperfusion salvage of threatened tissue. The chief risk is intracerebral hemorrhage.
With intravenous thrombolysis, about 6% of patients have intracerebral hemorrhage associated with early worsening,and half of these patients have their final outcome altered as a result. With intra-arterial thrombolysis, about 10% of patients have major early hemorrhage, but again many of these occur in already infarcted fields and do not clearly alter final outcome. Other less frequent complications of thrombolytics include systemic hemorrhage, angioedema, and allergic reactions.
Further Inpatient Care
After thrombolytic therapy is initiated, transfer the patient to an intensive care unit, stroke unit, or other unit capable of close observation. No antiplatelet or anticoagulant therapy should be administered for 24 hours following tPA.
Obtain a repeat head CT scan or MRI 24 hours after tPA to rule out asymptomatic hemorrhagic transformation prior to initiating antithrombotic therapy. Blood pressure should be monitored closely and controlled. Physical, occupational, and speech therapy can be initiated after the first 24 hours of bedrest.
Obtain neurosurgery and hematology consultation.
Transfer should be initiated if CT or MRI is not available. However, remember that the time to transfer a patient may exceed the 3-hour time-window for treatment.
In the NINDS trials, the rate of combined minor and major symptomatic ICH (ie, any clinical worsening temporally coincident with any new ICH) 24-36 hours after treatment was 6.4% with tPA versus 0.6% without tPA.
ICH may be signaled by acute hypertension, headache, neurological deterioration, and nausea or vomiting. If ICH is suspected, obtain an emergent head CT scan and obtain PT, aPTT, platelet count, and fibrinogen. If ICH is present on CT scan, evaluate lab studies and administer, if needed, 6-8 units of cryoprecipitate containing fibrinogen and factor VIII, 6-8 units of platelets, and/or fresh frozen plasma. Use of recombinant factor VII may also be considered but carries a risk of inducing thrombotic events.
Other complications may include oozing from intravenous line and venous puncture sites (up to 30% of cases) and angioedema, although this is rare.
Three months following tPA therapy, approximately 30% of patients are neurologically normal or near normal; 30% have mild to moderate neurological deficits; 20% have moderate to severe neurological deficits; and 20% have died.
Three months following tPA therapy, approximately 50% of patients are completely or almost completely independent in activities of daily living; 15% are moderately dependent on others; 15% are completely dependent on others; and 20% have died.
Education regarding the availability of thrombolytic therapy for stroke is important for patients with risk factors for stroke and those who have experienced a transient ischemic attack or prior stroke.
Emphasizing the importance of arriving at the hospital as early as possible for treatment is imperative.
The 4 main warning signs of an acute ischemic stroke are the following:
Sudden weakness or numbness on one side of the body
Sudden loss or change of vision
Sudden speech difficulty or language comprehension difficulty
Sudden dizziness or gait difficulty