IV-tPA ✘

Scientific Rationale for the Inclusion and Exclusion Criteria

R1 Jin-Yi Hsu

Inclusion criteria

< 3hours

Ischemic stroke

Age 18 - 80

Time

H & P

Lab

Image

3 hours

IV-tPA process

IV-tPA check list

✘

IV-tPA check list

Neuro Non- Neuro

SystemicPlatelet/ aPTT/ INR

Blood sugar/ Blood pressure

NIHSS < 4NIHSS > 25

Time

H & P

Lab

Image

3 hours

IV-tPA process

sICHHemorrhage

t-PA treatment rate

Hospital-based

20-30%

t-PA treatment rate

National-based

3-5%

Hospital-based

20-30%

Delay in presentation

t-PA treatment rate

Delay in presentation

t-PA treatment rate

Potential treatable, modifiable or reversible

before t-PA

Delay in presentation

Potential treatable, modifiable or reversible

before t-PA

Controversial criteria

t-PA treatment rate

IV-tPA evaluation

43 recommendation

Class I Class IIa Class IIb Class III

IV-tPA evaluation

43 recommendation

Class I

Class IIa

Class IIb

Class III

Class I

Class IIa

Class IIb

Class III

IV-tPA evaluation

43 recommendation

Class I

Class IIa

Class IIb

Class III

Class I

Class IIa

Class IIb

Class III

Time

3 hours

Age

Age

80 y/o

18 y/o

Equal Outcome

Time

3 hours

Age

Age

80 y/o

18 y/o

Risk elevation

Time

3 hours

Age

Age

80 y/o

18 y/o

Time

3 hours

Onset time

4.5 hours

As fast as possible

Time

3 hours

Onset time

4.5 hours

Not DM & CVANIHSS < 25No OACs

Ischemic zone not reach 1/3 MCA

Age < 80

NINDS

Time

3 hours

Onset time

4.5 hours

Not DM & CVANIHSS < 25No OACs

Age < 80

ECASS III

Time

3 hours 4.5 hours

IV t-PA Inclusion

Age

80 y/o

18 y/o

ECASS III

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

Stroke severity

4 25NIHSS

Stroke severity

4 25NIHSS

< 3 hours

Stroke severity

4 25NIHSS

< 3 hoursDisability

Stroke severity

4 25NIHSS

< 3 hoursNo Disability

Rapid improving

Remain moderately impaired

Potential disabled

Rapid improving

Remain moderately impaired

Potential disabled

Don’t wait to observe severity

Ischemic stroke within 3 months

History of ICH

Previous ICH

History of ICH

Cerebral microbleeds

Suspicion of SAH clinically

Un-ruptured intracranial aneurysm

< 1cm

Un-ruptured intracranial aneurysm

>1cm

Intravascular malformation

Intra-cranial neoplasm

Intra-axialParenchymal lesion

Intra-cranial neoplasm

Extra-axialNon-parenchymal lesion

ICH on CT

Severe

EICs on CT

Mild/Moderate

EICs on CT

Intracranial/ Spinal surgery within 3 months

Major surgery within 14 days

Individualized

Severe head injury within 3 months

Post-traumatic infarction

Major trauma within 14 Days

Carefully considered

Seizure at stroke onset

Real Weakness?

Post-Ictal?

Acute myocardial infarction

PCI first

Then IV-tPA

Recent MI within 3 months

NSTEMI

STMEI, RCA

Recent MI within 3 months

STEMI, LM

Endovascular complication

Aortic arch dissectionAortic arch dissection

Extra-cranial artery dissection

Intra-cranial artery dissection

Endocarditis

Pericarditis

Severe stroke

t-PA is reasonable

Pericarditis

Mild stroke

Not well established

L’t heart thrombus

Severe stroke

t-PA is reasonable

L’t heart thrombus

Mild stroke

Not well established

Intracardiac mass

Severe stroke

Maybe reasonable

0 24Drug administration

SBP < 185 mmHg DBP < 110mmHg

Blood pressure

Blood pressure

0 24Drug administration

SBP < 180 mmHg DBP < 105mmHg

50 400Bloodsugar

Blood sugar

50 400Bloodsugar

Blood sugar

50 400Bloodsugar

Blood sugar

50 400Bloodsugar

Stroke mimics

Blood sugar

Platelet & Coagulation

Platelet < 100000

INR > 1.7

aPTT > 40 seconds

PT > 15 seconds

Platelet & Coagulation

Extremely low risk

No reason to wait lab data

Warfarin

LMWH

Rivaroxaban

Dabigatran

Anti-coagulant

Warfarin

LMWH

Rivaroxaban

Dabigatran

INR > 1.7

Anti-coagulant

Warfarin

LMWH

Rivaroxaban

Dabigatran

Within 24 hrs

Anti-coagulant

Warfarin

LMWH

Rivaroxaban

Dabigatran Within 48 hrsaPTT/ INR/ Plt/ ECT TT/ Direct factor Xa

Anti-coagulant

Concurrent anti-platelet

0 24t-PA

AspirinClopedigrol

Concurrent anti-platelet

0 24t-PA

Anti-plateletDual anti-platelet

Low sICH risk

GI bleeding in recent 21 days

Harmful

Hx of bleeding diathesis/ coagulopathy

Individualized

Diabetic hemorrhagic retinopathy

Visual loss risk ⬆

Menstruation & Menorrhagia

Menstruation

Menstruation & Menorrhagia

Menorrhagia

Menstruation & Menorrhagia

Menstruation

Menorrhagia

Non-compressible vessel pucnture within 7 days

Uncertain

Dural puncture within 7 days

Maybe considered

ESRD with normal aPTT

Comorbidity

Dementia

Malignancy

Comorbidity

Give IV t-PA, even no consent

✘

Consent

Psychogenic stroke mimics

Extremely low risk

No reason to wait

Drug use ( Cocaine)

Pregnancy

Moderate-Severe

Post-partum ( < 14 days)

Not well established

Part 1

Part 2

Part 3

IV-tPA check list

• ( Microbleeds

• Actilyse

• 3

• 3

• 3 NSTEMI& STEMI-RCA, STEMI-LM

• 21

• 14

• 10

Part 1IV-tPA check list

• 3

• ( NIHSS < 4

• ( NIHSS > 25

• (

• SBP > 185 mmHg or DBP > 110mmHg

• (Intra-axial VS. Extra-axial) ( <1cm VS. >1cm)

•

•

Part 2IV-tPA check list

•

•

•

• (

•

Part 2IV-tPA check list

Part 3IV-tPA check list• 48 heparin aPTT

• INR > 1.7

• < 100000/mm3

• < 50mg/dL > 400mg/dL

• ( EIC > 1/3 MCA territory)

• 10

•

Neuro Non- Neuro

SystemicPlatelet/ aPTT/ INR

Blood sugar/ Blood pressure

NIHSS < 4NIHSS > 25

Neuro Non- Neuro

SystemicPlatelet/ aPTT/ INR

Blood sugar/ Blood pressure

NIHSS < 4NIHSS > 25

Thanks for your attention

R1 Jin-Yi Hsu

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Conclusion

Clear benefit• Alteplase treatment in elderly stroke patients

• Severe stroke

• Diabetes mellitus and hyperglycemia

• Minor early ischemic changes (EIC)

IV-tPA check list• ( Microbleeds

• Actilyse

• 3

• 3

• 21

• 4.5

•

•

Revised

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

Thanks for your attention

R1 Jin-Yi Hsu

✔✔✔

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