Apr 15, 2024
Contributor: Travis Barlock MD
Educational Pearls:
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Thrombolytic therapy (tPA or TNK) is often used in the ED for strokes
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Use of anticoagulants with INR > 1.7 or PT >15
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Warfarin will reliably increase the INR
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Current use of Direct thrombin inhibitor or Factor Xa inhibitor
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aPTT/PT/INR are insufficient to assess the degree of anticoagulant effect of Factor Xa inhibitors like apixaban (Eliquis) and rivaroxaban (Xarelto)
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Intracranial or intraspinal surgery in the last 3 months
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Intracranial neoplasms or arteriovenous malformations also increase the risk of bleeding
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Current intracranial or subarachnoid hemorrhage
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History of intracranial hemorrhage from thrombolytic therapy also contraindicates tPA/TNK
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Recent (within 21 days) or active gastrointestinal bleed
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Hypertension
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BP >185 systolic or >110 diastolic
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Administer labetalol before thrombolytics to lower blood pressure
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Timing of symptoms
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Onset > 4.5 hours contraindicates tPA
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Platelet count < 100,000
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BGL < 50
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Potential alternative explanation for stroke-like symptoms obviating need for thrombolytics
References
1. Fugate JE, Rabinstein AA. Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke. The Neurohospitalist. 2015;5(3):110-121. doi:10.1177/1941874415578532
2. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke a Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Vol 50.; 2019. doi:10.1161/STR.0000000000000211
Summarized by Jorge Chalit, OMSII | Edited by Jorge Chalit