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240 Cardio Diabetes Medicine 2017

90 days, although it was associated with a lower
• Sustained BP >185/110 mmHg despite treatment
risk of symptomatic intracerebral hemorrhage (which
• Platelets <1,00,000 ; HCT <25 % ; Glucose<50 was low in both treatment groups).
or >400 mg/dl
No other thrombolytic agent has been approved
• Use of heparin within 48hours and prolonged for use in ischemic stroke . In emergency de-
PPT, or elevated INR partments of medical centers with more limit-
• Rapidly improving symptoms ed capabilities, patients can receive the bolus
of rtPA and then be transferred to a primary
• Prior stroke or head injury within 3 months ; prior stroke centre while the rest of the dose of the
intracranial hemorrhage drug is being infused (the drip- and –ship strategy).
• Major surgery in preceding 14 days Hemorrhage is the most dangerous complication af-
ter thrombolysis.
• Minor stroke symptoms

• Gastrointestinal bleeding in preceding 21 days ACUTE ISCHEMIC STROKE
• Recent myocardial infarction The reported rates of symptomatic intracerebral
hemorrhage (sICH) have varied (between 1.9% and
• Coma or stupor 6.4%), depending on its definition and the design
Recenty, the indications and contra indications for of the study . However, most cases of SICH are
IV rtPA have been revisited in a scientific state- caused by reperfusion injury and worsen strokes
ment of the American Heart Association(AHA) and that were already severe and destined to be disabling.
modified by the FDA in the package insert for the Hemorrhagic transformation of a large infarction can
drug. As a result, more patients can be considered for increase the risk of death, but sICH rarely negates
IV thrombolysis in clinical practice. IV thrombolysis what would have otherwise been a good recovery.
should not be withheld because of advanced age, The risk of SICH is increased with old age , diabetes
and mild but disabling deficits justify treatment. In- mellitus, severe hyperglycemia uncontrolled hyper-
dividualized clinical judgment is necessary when tension and large hypodensity on baseline CT scan.
deciding whether to recommend thrombolysis The risk of sICH might also be higher in patients with
to patients with weaker indications (such as non cerebral microbleeds, although this association is not
disabling deficits)or relative contraindications. The entirely certain. When sudden neurologic decline oc-
safety and efficacy of IV thrombolysis in pediatric curs during rtPA infusion , the infusion should be im-
patients (younger than 18 years of age) is not well mediately stopped and a CT san should be obtained
established. emergently, whenever postthrombolysis sICH is di-
agnosed, treatment consists of control of hyperten-
IV rtPA infused within 3 hours of symptom onset in- sion (systolic target 140 mm Hg to 160mm Hg ) and
creases the chances of functional independence at reversal of the fibrinolytic effect with cryoprecipitate
3 month by one- third. The benefit is time dependent (10units) or an antifibrinolytic agent (Tranexemic acid
and much stronger when the drug is administered 10mg/Kg to 15 mg/Kg IV over 20 minutes or Amino
within the first 90 minutes after symptom onset. Old- caproic acid 5Grams IV followed by an infusion of
er patients and those with a very severe stroke 1Gram/hour if needed).Additional cryoprecipitate may
at presentation have worse prognosis but can still be given if the serum fibrinogen level remains below
benefit from IV rtPA. The benefit is less robust for 150mg/dl. Orolingual angioedema is a rare but po-
patients treated between 3 and 4.5hours , but rtPA tentially serious complication of rtPA administration.
is still beneficicial in this extended window . The risk is higher in patients previously taking an-
The standard dose of IV rtPA for acute ischemic giotensin converting enzyme inhibitors. It is typically
stroke is 0.9mg/kg with 10% administered as a bolus asymmetric and tends to involve the hemiparetic side
and the remainder infused over 1 hour. The total the most severe cases can compromise airway pa-
dose should not exceed 90mg.The phase 3 Enhanced tency thus careful monitoring is indispensable. Treat-
control of Hypertension and thrombolysis stroke ment consists of a combination of diphenhydramine
study (ENCHANTED) enrolled 3310 predominantly (50mg IV),ranitidine (50 mg IV),and dexametha-
Asian patients to receive either 0.9mg/kg or 0.6mg/ sone(10 mg IV).
kg of IV rtPA within 4.5 hours of stroke onset. The While IV thrombolysis is the standard of care for eligi-
reduced dose was inferior to the standard dose for ble patients with acute ischemic stroke,this treatment
the end point of death or any degree of disability at has limitations. In addition to its short time window

GCDC 2017