Treatment
Intravenous Fibrinolysis
ÎÎAdminister IV rtPA (0.9 mg/kg, maximum dose 90 mg) to selected
patients who may be treated within 3 hours of onset of ischemic stroke
(I-A).
Notes: Physicians should review the criteria outlined in Tables 8 and 9 (which are
modeled on those used in the National Institute of Neurologic Disorders and Stroke
rt-PA Stroke Study) to determine the eligibility of the patient.
A recommended regimen for observation and treatment of patients who receive
IV rtPA is described in Table 10.
ÎÎIn patients eligible for IV rtPA, the benefit of therapy is time
dependent, and treatment should be initiated as quickly as possible.
The door-to-needle time (time of bolus administration) should be
within 60 minutes from hospital arrival (I-A).
ÎÎAdminister IV rtPA (0.9 mg/kg, maximum dose 90 mg) to eligible
patients who can be treated 3-4.5 hours after stroke onset (I-B).
Note: The eligibility criteria for treatment in this time period are similar to those for
people treated at earlier time periods within 3 hours, with the additional exclusion
criteria listed in Table 9.
ÎÎIV rtPA is reasonable in patients whose BP can be lowered safely (to
<185/110 mm Hg) with antihypertensive agents, with the physician
assessing the stability of the BP before starting IV rtPA (I-B).
ÎÎIn patients undergoing fibrinolytic therapy, physicians should be aware
of and prepared to treat potential side effects emergently, including
bleeding complications and angioedema that may cause partial airway
obstruction (I-B).
ÎÎIV rtPA is reasonable in patients with a seizure at the time of onset of
stroke if evidence suggests that residual impairments are secondary
to stroke and not a postictal phenomenon (IIa-C).
ÎÎThe effectiveness of sonothrombolysis for treatment of patients with
acute stroke is not well established (IIb-B).
ÎÎThe usefulness of IV administration of tenecteplase, reteplase,
desmoteplase, urokinase, or other fibrinolytic agents and the IV
administration of ancrod or other defibrinogenating agents is not well
established. They should be used only in the setting of a clinical trial
(IIb-B).
ÎÎFor patients who can be treated in the time period of 3-4.5 hours after
stroke but have one or more of the exclusion criteria listed in Table 9,
the effectiveness of IV treatment with rtPA is not well established
(IIb-C) and requires further study.
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