Reperfusion therapy in acute ischemic stroke: Case-based Simulations Mloganzila Stroke Workshop presentation by Dr. Basil Tumaini

1. Case-based simulation:
Reperfusion therapy in acute
ischemic stroke
Dr. Basil Tumaini
Neurologist and Lecturer
Muhimbili University of Health and Allied Sciences
Mloganzila Stroke Workshop | 22nd May 2025

2. 2
Contraindications to rtPA
“SAMPLE STAGES” [absolute, relative]
• S Stroke (AIS) or head trauma - last 3 months,
SOL/intracranial neoplasm
• A Anticoagulation (on); INR>1.7, PT>15s,
aPTT>40s; DTL, DFXaI, GpIIb/IIIa I (last dose
within 48h); active internal bleeding, aortic
arch dissection, acute bleeding diathesis, arterial
puncture NCS in 7d
• M MI in prior 3months (recent)

3. 3
Contraindications to rtPA . .
P Prior ICH, evidence of hemorrhage on CTH;
pregnancy; intracranial vascular malformation; LMWH use
within 24hr for PE or DVT ℞
L Low platelet count <100,000/µL; large, untreated,
unruptured intracranial aneurysm
E Elevated BP: SBP ≥ 185, DBP ≥ 110 mm Hg
S Surgery, past 14 days; intracranial or spinal surgery,
past 3 months
T TIA, mild symptoms, rapid improvement
A Age < 18

4. 4
Contraindications to rtPA . . .
G GI/ urinary bleeding – past 14 days, malignancy,
infective endocarditis
E Elevated/ decreased blood glucose <50mg/dL
[2.7mmoL/L] or >400 mg/dL (22.2mmoL/L)
S Seizures at onset of stroke, SAH, extensive
regions of hypodensity on CTH consistent with
ischemic injury

5. 5
AcT trial
IV tenecteplase compared with alteplase for AIS in Canada
(AcT): a pragmatic, multicentre, open-label, registry-
linked, randomised, controlled, non-inferiority trial
 Tenecteplase is non-inferior to alteplase for achieving
functional independence at 90 days in patients with
AIS
 The safety profiles were similar, with no significant
differences in sICH or mortality between the two
groups
 Tenecteplase may offer a higher rate of early
recanalization compared to alteplase

6. 6
Comparison: thrombolysis vs. thrombectomy
Indications:
 Thrombolysis: early treatment, smaller clots
 Thrombectomy: large vessel occlusions, extended
time window
Combination Therapy:
 Sometimes used together for optimal results

7. 7
Comparison: thrombolysis vs. thrombectomy
Success Rates:
 Thrombectomy: ~60-70% recanalization
 Thrombolysis: ~30% success in large vessels
Limitations:
 Thrombolysis: time-sensitive, risk of bleeding
 Thrombectomy: resource-intensive, not widely available

8. 8
Landmark thrombectomy trials
Trial
Name
Journal
, Year
Results Conclusion
SELECT
2
NEJM,
2023
Showed that
thrombectomy in patients
with large infarcts
resulted in better
functional outcomes than
medical therapy alone
Thrombectomy
is beneficial
even in patients
with large
infarcts,
challenging
previous
exclusion
criteria based on
infarct size

9. 9
Landmark thrombectomy trials
Trial
Name
Journal,
Year
Results Conclusion
DAWN NEJM,
2018
Demonstrated that
thrombectomy up to 24
hours after stroke onset
significantly improved
functional outcomes in
patients with a small
infarct core and large
clinical deficit
Mechanical
thrombectomy is
beneficial in
selected patients
with large vessel
occlusion stroke
even up to 24
hours after onset

10. Case 1: Standard IV thrombolysis
 67-year-old male with left-sided weakness.
 Last seen well: 1.5 hours ago.
 NIHSS: 10, CT normal.
 BP: 160/90, Glucose: 6.3 mmol/L.
 ️
🗣️Discussion:
 Is he eligible for IV tPA?
 ✅ Answer:
 Yes – meets all inclusion criteria.

11. Case 2: Wake-Up Stroke with DWI-FLAIR
Mismatch
• 74-year-old female, found with aphasia at 6 AM, last seen
normal at 10 PM.
• MRI: DWI-FLAIR mismatch.
• ️
🗣️Discussion:
• Eligible for thrombolysis?
• ✅ Answer:
• Yes – MRI-guided thrombolysis supported by WAKE-UP
trial.

12. Case 3: Mechanical Thrombectomy within 6
hours
• 58-year-old male, sudden aphasia and right hemiplegia at
9 AM.
• Arrival at 11 AM. CTA: Left MCA M1 occlusion.
• ASPECTS 9, NIHSS 20.
• ️
🗣️Discussion:
• Thrombectomy indicated?
• ✅ Answer:
• Yes – large vessel occlusion within 6-hour window.

13. Case 4: Extended Window Thrombectomy
(DAWN Criteria)
• 63-year-old woman, found aphasic at 7 AM, last seen well
at 10 PM (11 hrs).
• CTA: Right ICA occlusion, perfusion scan shows mismatch.
• 🗣️Discussion:
• Eligible for thrombectomy?
• ✅ Answer:
• Yes – DAWN/DEFUSE 3 trials support use up to 24 hrs if
mismatch exists.

14. Case 5: Recent Surgery
• 70-year-old male, right hemiparesis.
• Recent spinal surgery 10 days ago.
• BP: 175/95, INR: 1.1.
• 🗣️Discussion:
• Eligible for tPA?
• ✅ Answer:
• No – recent major surgery within 14 days is a
contraindication.

15. Case 6: Severe Hypertension
• 62-year-old woman, onset 2 hours ago.
• BP: 220/120 despite 3 doses IV labetalol.
• ️
🗣️Discussion:
• Can we give tPA?
• ✅ Answer:
• No – uncontrolled BP ≥185/110 is an absolute
contraindication.

16. Case 7: Large Infarct Core
• 75-year-old male, symptoms began 4 hours ago.
• ASPECTS = 3.
• 🗣️Discussion:
• Thrombectomy suitable?
• ✅ Answer:
• No – large core infarct with minimal penumbra is a
contraindication.

17. Case 8: Coagulopathy
• 55-year-old female, on warfarin, INR = 2.4.
• Stroke symptoms for 2 hours.
• ️
🗣️Discussion:
• Proceed with tPA?
• ✅ Answer:
• No – INR >1.7 contraindicates tPA use.

18. Case 9: Hemorrhagic Transformation
• 60-year-old male received tPA 1.5 hours after onset.
• 2 hours later: sudden drop in GCS, vomiting.
• CT: new large ICH.
• 🗣️Discussion:
• How to manage post-tPA bleed?
• ✅ Answer:
• Stop infusion, reverse coagulopathy, manage BP; refer to
hemorrhage protocol.

19. Case 10: Orolingual Angioedema
• 68-year-old woman, tPA started 30 mins ago.
• Tongue swelling and stridor developing.
• 🗣️Discussion:
• Next step?
• ✅ Answer:
• Stop tPA, protect airway, administer
antihistamines/steroids.

20. Case 11: Reperfusion Injury
• 73-year-old male underwent successful thrombectomy.
• 6 hrs later: worsening edema and GCS decline.
• CT: Massive edema with midline shift.
• ️
🗣️Discussion:
• Diagnosis and management?
• ✅ Answer:
• Reperfusion injury; ICU care, neurosurgical consult.

21. Case 12: Missed Stroke Mimic
• 65-year-old diabetic woman, expressive aphasia and right
hemiparesis.
• tPA given, later found to have hypoglycemia (glucose 2.5
mmol/L).
• ️
🗣️Discussion:
• How could this have been avoided?
• ✅ Answer:
• Always check glucose before thrombolysis; treat and reassess if
low.