Clinical Guidelines for Acute Stroke Management - Living on the EDge

Intravenous rt-PA was licensed by the Australian
Therapeutic Goods Administration <strong>for</strong> use in acute
ischaemic stroke in October 2003. While it is not
feasible <strong>for</strong> all hospitals to deliver stroke thrombolysis
due to local resources, a number of Australian
hospitals with organised stroke care and acute stroke
Patient Selection Criteria
Indications
units have demonstrated an ability to safely administer
rt-PA. 127, 128 Table 2 outlines the patient selection
criteria <strong>for</strong> the safe and effective delivery of rt-PA.
These criteria are adapted from the inclusion and
exclusion criteria <strong>for</strong> the NINDS rt-PA trial. 129 23
1 Onset of ischaemic stroke within the preceding 3 hours.
2 Measurable and clinically significant deficit on NIH <strong>Stroke</strong> Scale examination.
3 Patient's computed tomography (CT) does not show haemorrhage or non-vascular cause of stroke.
4 Patient's age is >18 years.
Contraindications: ABSOLUTELY Do NOT administer tPA if any of these statements are true:
1 Uncertainty about time of stroke onset (e.g. patients awaking from sleep)
2 Coma or severe obtundation with fixed eye deviation and complete hemiplegia.
3 Only minor stroke deficit which is rapidly improving.
4 Seizure observed or known to have occurred at onset of stroke.
5 Hypertension: systolic blood pressure ≥ 185mmHg; or diastolic blood pressure >110mmHg on repeated
measures prior to study.
6 <strong>Clinical</strong> presentation suggestive of subarachnoid haemorrhage even if the CT scan is normal.
7 Presumed septic embolus.
8 Patient having received heparin with the last 48 hours and has elevated PTT or has a known hereditary
or acquired haemorrhagic diathesis (e.g. PT or APTT greater than normal).
9 INR >1.5.
10 Platelet count is 22.0 mmol/l.
Section 4 <strong>Acute</strong> Medical & Surgical <strong>Management</strong>
RELATIVE Contraindications: If any of the following statements is true, use tPA with caution.
In each situation careful consideration of the balance of the potential risks and benefits must be given:
1 Severe neurological impairment with NIH <strong>Stroke</strong> Scale score >22.
2 Age >80 years.
3 CT evidence of extensive middle cerebral artery (MCA) territory infarction (sulcal effacement or blurring of
gray-white junction in greater than 1/3 of MCA territory).
4 <strong>Stroke</strong> or serious head trauma within the past 3 months where the risks of bleeding are considered to
outweigh the benefits of therapy.
5 Major surgery within the last 14 days.
6 Patient has known history of intracranial haemorrhage, subarachnoid haemorrhage, known intracranial
arteriovenous mal<strong>for</strong>mation or previously known intracranial neoplasm that, in the opinion of the clinician,
the increased risk of intracranial bleeding would outweigh the potential benefits of treatment.
7 Suspected recent (within 30 days) myocardial infarction.
8 Recent (within 30 days) biopsy of a parenchymal organ or surgery that, in the opinion of the responsible
clinician, would increase the risk of unmanageable (e.g. uncontrolled by local pressure) bleeding.
9 Recent (within 30 days) trauma with internal injuries or ulcerative wounds.
10 Gastrointestinal or urinary tract haemorrhage within the last 30 days or any active or recent haemorrhage
that, in the opinion of the responsible clinician, would increase the risk of unmanageable (e.g. by local
pressure) bleeding.
11 Arterial puncture at noncompressible site within the last 7 days.
12 Concomitant serious, advanced or terminal illness or any other condition that, in the opinion of the
responsible clinician would pose a risk to treatment.
Table 2: Patient section criteria <strong>for</strong> potential eligibility <strong>for</strong> rt-PA