Contributor: Travis Barlock MD

Educational Pearls:

• Thrombolytic therapy (tPA or TNK) is often used in the ED for strokes

• Use of anticoagulants with INR > 1.7 or  PT >15

• • Warfarin will reliably increase the INR

• Current use of Direct thrombin inhibitor or Factor Xa inhibitor

• • aPTT/PT/INR are insufficient to assess the degree of anticoagulant effect of Factor Xa inhibitors like apixaban (Eliquis) and rivaroxaban (Xarelto)

• Intracranial or intraspinal surgery in the last 3 months

• • Intracranial neoplasms or arteriovenous malformations also increase the risk of bleeding

• Current intracranial or subarachnoid hemorrhage

• • History of intracranial hemorrhage from thrombolytic therapy also contraindicates tPA/TNK

• Recent (within 21 days) or active gastrointestinal bleed

• Hypertension

• • BP >185 systolic or >110 diastolic

  • Administer labetalol before thrombolytics to lower blood pressure

• Timing of symptoms

• • Onset > 4.5 hours contraindicates tPA

• Platelet count < 100,000

• BGL < 50

• • 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