20160919 Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke
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Stroke is one of the most common cause result in disability, and alteplase infusion could help patient to improve the function status on 3 months. 中風是最常見造成失能的原因之一，而早期給予血栓溶解劑可以改善病人三個月後生活功能恢復情況。
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20160919 Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke
- 1. IV-tPA ✘ Scientific Rationale for the Inclusion and Exclusion Criteria R1 Jin-Yi Hsu
- 2. Inclusion criteria < 3hours Ischemic stroke Age 18 - 80
- 3. Time H & P Lab Image 3 hours IV-tPA process
- 6. Neuro Non- Neuro Systemic Platelet/ aPTT/ INR Blood sugar/ Blood pressure NIHSS < 4 NIHSS > 25
- 7. Time H & P Lab Image 3 hours IV-tPA process sICH Hemorrhage
- 10. Delay in presentation t-PA treatment rate
- 11. Delay in presentation t-PA treatment rate Potential treatable, modifiable or reversible before t-PA
- 12. Delay in presentation Potential treatable, modifiable or reversible before t-PA Controversial criteria t-PA treatment rate
- 13. IV-tPA evaluation 43 recommendation Class I Class IIa Class IIb Class III
- 14. IV-tPA evaluation 43 recommendation Class I Class IIa Class IIb Class III Class I Class IIa Class IIb Class III
- 15. IV-tPA evaluation 43 recommendation Class I Class IIa Class IIb Class III Class I Class IIa Class IIb Class III
- 16. Time 3 hours Age Age 80 y/o 18 y/o Equal Outcome
- 17. Time 3 hours Age Age 80 y/o 18 y/o Risk elevation
- 18. Time 3 hours Age Age 80 y/o 18 y/o
- 19. Time 3 hours Onset time 4.5 hours As fast as possible
- 20. Time 3 hours Onset time 4.5 hours Not DM & CVA NIHSS < 25 No OACs Ischemic zone not reach 1/3 MCA Age < 80 NINDS
- 21. Time 3 hours Onset time 4.5 hours Not DM & CVA NIHSS < 25 No OACs Age < 80 ECASS III
- 22. Time 3 hours 4.5 hours IV t-PA Inclusion Age 80 y/o 18 y/o ECASS III
- 23. 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
- 25. Stroke severity 4 25NIHSS < 3 hours
- 26. Stroke severity 4 25NIHSS < 3 hours Disability
- 27. Stroke severity 4 25NIHSS < 3 hours No Disability
- 28. Rapid improving Remain moderately impaired Potential disabled
- 29. Rapid improving Remain moderately impaired Potential disabled Don’t wait to observe severity
- 30. Ischemic stroke within 3 months
- 31. History of ICH Previous ICH
- 33. Suspicion of SAH clinically
- 39. ICH on CT
- 42. Intracranial/ Spinal surgery within 3 months
- 43. Major surgery within 14 days Individualized
- 44. Severe head injury within 3 months
- 46. Major trauma within 14 Days Carefully considered
- 47. Seizure at stroke onset Real Weakness? Post-Ictal?
- 48. Acute myocardial infarction PCI first Then IV-tPA
- 49. Recent MI within 3 months NSTEMI STMEI, RCA
- 50. Recent MI within 3 months STEMI, LM
- 52. Aortic arch dissectionAortic arch dissection
- 55. Endocarditis
- 56. Pericarditis Severe stroke t-PA is reasonable
- 57. Pericarditis Mild stroke Not well established
- 58. L’t heart thrombus Severe stroke t-PA is reasonable
- 59. L’t heart thrombus Mild stroke Not well established
- 60. Intracardiac mass Severe stroke Maybe reasonable
- 61. 0 24 Drug administration SBP < 185 mmHg DBP < 110mmHg Blood pressure
- 62. Blood pressure 0 24 Drug administration SBP < 180 mmHg DBP < 105mmHg
- 66. 50 400 Blood sugar Stroke mimics Blood sugar
- 67. Platelet & Coagulation Platelet < 100000 INR > 1.7 aPTT > 40 seconds PT > 15 seconds
- 68. Platelet & Coagulation Extremely low risk No reason to wait lab data
- 72. Warfarin LMWH Rivaroxaban Dabigatran Within 48 hrs aPTT/ INR/ Plt/ ECT TT/ Direct factor Xa Anti-coagulant
- 74. Concurrent anti-platelet 0 24t-PA Anti-platelet Dual anti-platelet Low sICH risk
- 75. GI bleeding in recent 21 days Harmful
- 76. Hx of bleeding diathesis/ coagulopathy Individualized
- 77. Diabetic hemorrhagic retinopathy Visual loss risk
- 81. Non-compressible vessel pucnture within 7 days Uncertain
- 82. Dural puncture within 7 days Maybe considered
- 83. ESRD with normal aPTT Comorbidity
- 85. Give IV t-PA, even no consent ✘ Consent
- 86. Psychogenic stroke mimics Extremely low risk No reason to wait
- 87. Drug use ( Cocaine)
- 89. Post-partum ( < 14 days) Not well established
- 90. Part 1 Part 2 Part 3 IV-tPA check list
- 91. • ( Microbleeds • Actilyse • 3 • 3 • 3 NSTEMI& STEMI-RCA, STEMI-LM • 21 • 14 • 10 Part 1IV-tPA check list
- 92. • 3 • ( NIHSS < 4 • ( NIHSS > 25 • ( • SBP > 185 mmHg or DBP > 110mmHg • (Intra-axial VS. Extra-axial) ( <1cm VS. >1cm) • • Part 2IV-tPA check list
- 93. • • • • ( • Part 2IV-tPA check list
- 94. Part 3IV-tPA check list • 48 heparin aPTT • INR > 1.7 • < 100000/mm3 • < 50mg/dL > 400mg/dL • ( EIC > 1/3 MCA territory) • 10 •
- 95. Neuro Non- Neuro Systemic Platelet/ aPTT/ INR Blood sugar/ Blood pressure NIHSS < 4 NIHSS > 25
- 96. Neuro Non- Neuro Systemic Platelet/ aPTT/ INR Blood sugar/ Blood pressure NIHSS < 4 NIHSS > 25 Thanks for your attention R1 Jin-Yi Hsu ✔ ✔ ✔ ✔
- 97. Conclusion Clear benefit • Alteplase treatment in elderly stroke patients • Severe stroke • Diabetes mellitus and hyperglycemia • Minor early ischemic changes (EIC)
- 98. IV-tPA check list • ( Microbleeds • Actilyse • 3 • 3 • 21 • 4.5 • • Revised
- 99. 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
- 100. Thanks for your attention R1 Jin-Yi Hsu ✔ ✔ ✔ ✔