IV-tPA ✘
Scientific Rationale for the Inclusion and Exclusion Criteria
R1 Jin-Yi Hsu
Inclusion criteria
< 3hours
Ischemic stroke
Age 18 - 80
Time
H & P
Lab
Image
3 hours
IV-tPA process
✘
IV-tPA check list
Neuro Non- Neuro
SystemicPlatelet/ aPTT/ INR
Blood sugar/ Blood pressure
NIHSS < 4NIHSS > 25
Time
H & P
Lab
Image
3 hours
IV-tPA process
sICHHemorrhage
t-PA treatment rate
Hospital-based
20-30%
t-PA treatment rate
National-based
3-5%
Hospital-based
20-30%
Delay in presentation
t-PA treatment rate
Delay in presentation
t-PA treatment rate
Potential treatable, modifiable or reversible
before t-PA
Delay in presentation
Potential treatable, modifiable or reversible
before t-PA
Controversial criteria
t-PA treatment rate
IV-tPA evaluation
43 recommendation
Class I Class IIa Class IIb Class III
IV-tPA evaluation
43 recommendation
Class I
Class IIa
Class IIb
Class III
Class I
Class IIa
Class IIb
Class III
IV-tPA evaluation
43 recommendation
Class I
Class IIa
Class IIb
Class III
Class I
Class IIa
Class IIb
Class III
Time
3 hours
Age
Age
80 y/o
18 y/o
Equal Outcome
Time
3 hours
Age
Age
80 y/o
18 y/o
Risk elevation
Time
3 hours
Age
Age
80 y/o
18 y/o
Time
3 hours
Onset time
4.5 hours
As fast as possible
Time
3 hours
Onset time
4.5 hours
Not DM & CVANIHSS < 25No OACs
Ischemic zone not reach 1/3 MCA
Age < 80
NINDS
Time
3 hours
Onset time
4.5 hours
Not DM & CVANIHSS < 25No OACs
Age < 80
ECASS III
Time
3 hours 4.5 hours
IV t-PA Inclusion
Age
80 y/o
18 y/o
ECASS III
Time
3 hours 4.5 hours
IV t-PA Inclusion
Age
80 y/o
18 y/o
Not delaying IV-tPA due to obtain penumbral imaging
Stroke severity
4 25NIHSS
Stroke severity
4 25NIHSS
< 3 hours
Stroke severity
4 25NIHSS
< 3 hoursDisability
Stroke severity
4 25NIHSS
< 3 hoursNo Disability
Rapid improving
Remain moderately impaired
Potential disabled
Rapid improving
Remain moderately impaired
Potential disabled
Don’t wait to observe severity
Ischemic stroke within 3 months
History of ICH
Previous ICH
History of ICH
Cerebral microbleeds
Suspicion of SAH clinically
Un-ruptured intracranial aneurysm
< 1cm
Un-ruptured intracranial aneurysm
>1cm
Intravascular malformation
Intra-cranial neoplasm
Intra-axialParenchymal lesion
Intra-cranial neoplasm
Extra-axialNon-parenchymal lesion
Severe
EICs on CT
Mild/Moderate
EICs on CT
Intracranial/ Spinal surgery within 3 months
Major surgery within 14 days
Individualized
Severe head injury within 3 months
Post-traumatic infarction
Major trauma within 14 Days
Carefully considered
Seizure at stroke onset
Real Weakness?
Post-Ictal?
Acute myocardial infarction
PCI first
Then IV-tPA
Recent MI within 3 months
NSTEMI
STMEI, RCA
Recent MI within 3 months
STEMI, LM
Endovascular complication
Aortic arch dissectionAortic arch dissection
Extra-cranial artery dissection
Intra-cranial artery dissection
Pericarditis
Severe stroke
t-PA is reasonable
Pericarditis
Mild stroke
Not well established
L’t heart thrombus
Severe stroke
t-PA is reasonable
L’t heart thrombus
Mild stroke
Not well established
Intracardiac mass
Severe stroke
Maybe reasonable
0 24Drug administration
SBP < 185 mmHg DBP < 110mmHg
Blood pressure
Blood pressure
0 24Drug administration
SBP < 180 mmHg DBP < 105mmHg
50 400Bloodsugar
Blood sugar
50 400Bloodsugar
Blood sugar
50 400Bloodsugar
Blood sugar
50 400Bloodsugar
Stroke mimics
Blood sugar
Platelet & Coagulation
Platelet < 100000
INR > 1.7
aPTT > 40 seconds
PT > 15 seconds
Platelet & Coagulation
Extremely low risk
No reason to wait lab data
Warfarin
LMWH
Rivaroxaban
Dabigatran
Anti-coagulant
Warfarin
LMWH
Rivaroxaban
Dabigatran
INR > 1.7
Anti-coagulant
Warfarin
LMWH
Rivaroxaban
Dabigatran
Within 24 hrs
Anti-coagulant
Warfarin
LMWH
Rivaroxaban
Dabigatran Within 48 hrsaPTT/ INR/ Plt/ ECT TT/ Direct factor Xa
Anti-coagulant
Concurrent anti-platelet
0 24t-PA
AspirinClopedigrol
Concurrent anti-platelet
0 24t-PA
Anti-plateletDual anti-platelet
Low sICH risk
GI bleeding in recent 21 days
Harmful
Hx of bleeding diathesis/ coagulopathy
Individualized
Diabetic hemorrhagic retinopathy
Visual loss risk ⬆
Menstruation & Menorrhagia
Menstruation
Menstruation & Menorrhagia
Menorrhagia
Menstruation & Menorrhagia
Menstruation
Menorrhagia
Non-compressible vessel pucnture within 7 days
Uncertain
Dural puncture within 7 days
Maybe considered
ESRD with normal aPTT
Comorbidity
Dementia
Malignancy
Comorbidity
Give IV t-PA, even no consent
✘
Consent
Psychogenic stroke mimics
Extremely low risk
No reason to wait
Drug use ( Cocaine)
Pregnancy
Moderate-Severe
Post-partum ( < 14 days)
Not well established
Part 1
Part 2
Part 3
IV-tPA check list
• ( Microbleeds
• Actilyse
• 3
• 3
• 3 NSTEMI& STEMI-RCA, STEMI-LM
• 21
• 14
• 10
Part 1IV-tPA check list
• 3
• ( NIHSS < 4
• ( NIHSS > 25
• (
• SBP > 185 mmHg or DBP > 110mmHg
• (Intra-axial VS. Extra-axial) ( <1cm VS. >1cm)
•
•
Part 2IV-tPA check list
•
•
•
• (
•
Part 2IV-tPA check list
Part 3IV-tPA check list• 48 heparin aPTT
• INR > 1.7
• < 100000/mm3
• < 50mg/dL > 400mg/dL
• ( EIC > 1/3 MCA territory)
• 10
•
Neuro Non- Neuro
SystemicPlatelet/ aPTT/ INR
Blood sugar/ Blood pressure
NIHSS < 4NIHSS > 25
Neuro Non- Neuro
SystemicPlatelet/ aPTT/ INR
Blood sugar/ Blood pressure
NIHSS < 4NIHSS > 25
Thanks for your attention
R1 Jin-Yi Hsu
✔✔✔
✔
Conclusion
Clear benefit• Alteplase treatment in elderly stroke patients
• Severe stroke
• Diabetes mellitus and hyperglycemia
• Minor early ischemic changes (EIC)
IV-tPA check list• ( Microbleeds
• Actilyse
• 3
• 3
• 21
• 4.5
•
•
Revised
IV-tPA check list•
• 48 heparin aPTT > 40 secs
• INR > 1.7
• 48
• < 100000/mm3
• SBP > 185 mmHg or DBP > 110mmHg
• < 50mg/dL > 400mg/dL
• ( EIC > 1/3 MCA territory)
Revised
Thanks for your attention
R1 Jin-Yi Hsu
✔✔✔
✔