UMEM Educational Pearls

Category: Neurology

Title: So Who is Supposed to Get tPA for Stroke Nowadays?

Keywords: stroke, thrombolytics, tPA (PubMed Search)

Posted: 1/23/2019 by Danya Khoujah, MBBS
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Question

Intravenous (IV) thrombolytics for stroke remain a controversial topic for emergency medicine (EM) physicians, with numerous editorials and articles questioning the strength of the recommendations by the AHA in 2018. Nevertheless, it is prudent for the emergency medicine provider to be aware that administration of IV tPA is a Level I recommendation in any stroke patient with a time of onset (or last known normal) up to 4.5 hours in patients with no contraindications. Clinical judgement should always direct care, and documentation for deviation from the guidelines (if any) should be done.

Answer

The current AHA 2018 recommendations:

IV tPA is recommended for all stroke patients with an onset time below 3 hours in the absence of absolute contraindications. (Level I receommendation)
IV tPA is recommended for stroke patients with an onset time 3-4.5 hours in the absence of absolute contraindications, with the additional following contraindications: (Level I recommendation)
- Age ≥ 80 years
- History of prior stroke and diabetes
- Being on any anticoagulant irrelevant of the INR
- NIH stroke scale > 25
- Infarct territory encompassing >1/3 of the MCA territory
IV tPA can be considered in stroke patients with an onset time 3 - 4.5 hours in the absence of absolute contraindications, irrelevant of age, prior history of stroke and diabetes, or being on an anticoagulant. (Level II receommendation)
IV tPA should be given in all stroke patients as mentioned above even if they are being considered for endovascular thrombectomy.

References

Powers WJ et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49. DOI: 10.1161/STR.0000000000000158