When not to thrombolyse in Hyperacute Stroke: A clinical case series by Dr. Saumya

Thrombolysis has served as a catalyst for major changes in the management of acute ischemic stroke & is the approved method for the emergency treatment of stroke. One should be cognizant of the indications & contraindications of when one should thrombolyse & when not in such cases. Learn through this case series depicting when not to use thrombolysis in cases of stroke presented by Dr. Saumya H Mittal Follow us for more such updates!



A very informative clinical case series has been presented by Dr Saumya .H.Mittal and he himself have justified in this Experts Insights clinical case that thrombolysis is not to be done in all cases of hyoeracute stroke as it may do more harm and clinical deterioration than improvement. It is a specialized job and itit should always be done in aan advanced hospital setting supervised by a neurologist. This is a example that why superspecialists are required in some clinical settings He have already enumerated the contraindications elaborately Congratulations- Sir .........But the Recommendations of thrombolysis are : 1. Intravenous r-TPA (0.9 mg/kg, maximum 90 mg) with 10% of the dose given as a bolus followed by an infusion lasting 60 minutes is recommended treatment within 3 hours of onset of ischemic stroke (Grade A recommendation). The benefit of intravenous r-TPA for acute ischemic stroke beyond 3 hours from onset of symptoms is not established. At this time intravenous administration of r-TPA for a person who has had a stroke more than 3 hours earlier cannot be recommended outside the clinical investigation setting. Intravenous r-TPA is not recommended when the time of onset of stroke cannot be ascertained reliably, including strokes recognized upon awakening. 2. Intravenous administration of streptokinase outside the clinical investigation setting is not indicated for management of ischemic stroke (Grade A recommendation). Data on the efficacy or safety of any other intravenously administered thrombolytic drug are not available to provide a recommendation. 3. Thrombolytic therapy is not recommended unless the diagnosis is established by a physician with expertise in diagnosis of stroke and CT of the brain is assessed by physicians with expertise in reading this imaging study. If CT demonstrates early changes of a recent major infarction such as sulcal effacement, mass effect, edema, or possible hemorrhage, thrombolytic therapy should be avoided (Grade A recommendation). 4. Thrombolytic therapy cannot be recommended for persons excluded from the NINDS Study6 for one of the following reasons: Current use of oral anticoagulants or a prothrombin time greater than 15 seconds (International Normalized Ratio [INR] greater than 1.7); use of heparin in the previous 48 hours and a prolonged partial thromboplastin time; a platelet count less than 100 000/mm3; another stroke or a serious head injury in the previous 3 months; major surgery within the preceding 14 days; pretreatment systolic blood pressure greater than 185 mm Hg or diastolic blood pressure greater than 110 mm Hg; rapidly improving neurological signs; isolated, mild neurological deficits, such as ataxia alone, sensory loss alone, dysarthria alone, or minimal weakness; prior intracranial hemorrhage; blood glucose less than 50 mg/dL or greater than 400 mg/dL; seizure at the onset of stroke; gastrointestinal or urinary bleeding within the preceding 21 days; or recent myocardial infarction. 5. Thrombolytic therapy should not be given unless the emergent ancillary care (below) and the facilities to handle bleeding complications are readily available. 6. Caution is advised before giving r-TPA to persons with severe stroke (NIH Stroke Scale Score greater than 22). 7. Because the use of thrombolytic drugs carries the real risk of major bleeding, whenever possible the risks of potential benefits of r-TPA should be discussed with the patient and his or her family before treatment is initiated.

Chd me seva ka mokka do miller kam krege

Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!

Thrombolysis is a life saving step in cases of stroke but carries the real risk of bleeding if possible prognosis explained to pts near and dear and associated life threatening complications must be kept in mind but in most cases guildlines of must be strictly followed and require constant evaluation and regular monitoring of pts condition.

Thanks Dr Anil Gangani

View 2 other replies

When "not to use" is more important and beneficial then "to b used". In town level many pts r brought to proper centers too late or after the golden period is over. So, thanks to elobarate about the contra indication.

Thrmollysis is very beneficial life saving in cases of stroke but hast be used with caution as there are chances bleeding with associated life threatening complications


Nice presentation

Can be used under guidens of neuro physicians but use without guideline is dengers

Good information

Congratulations sir

Load more answers

Cases that would interest you