Stroke Guidelines

Question 1

Which drug is currently used for stroke thrombolysis and what is the thrapeutic window?

In which case can the therapeutic window for thrombolysis be extended?

Answer 1

intravenous alteplase 0,9mg/Kg

Therapeutic window is <4,5 hours

The therapeutic window can be extended up to 9 hours from stroke onset when

i) there is a CT or MRI core/ perfusion missmatch*, AND
ii) mechanical thrombectomy is either not indicated or not planned

* *In the individual participant data metaanalysis
 core/perfusion
mismatch was assessed with an
automated processing software and
defined as follows:
- Infarct core** volume<70 ml
- and Critically hypoperfused† volume/ Infarct
core** volume>1.2
- and Mismatch volume>10 ml
** rCBF <30% (CT perfusion) or ADC<620
mm2/s (Diffusion MRI)
† Tmax >6 s (perfusion CT or perfusion MRI)

Question 2

Wake-up stroke management

Answer 2

If last seen well <4,5h –> treatment with IV alteplase

If last seen well >4,5h –> if MRI DWI-FLAIR mismatch AND thrombectomy not indicated or planned –> treatment with IV alteplase

If there is CT or MRI core/perfusion mismatch within 9 hours from the midpoint of sleep AND thrombectoy is not indicated or not planned –> treatment with IV alteplase

Question 3

In large vessel occlusion and candidates for thrombectomy, which thrombolysis treatment is prefered?

Answer 3

Treatment with IV tenecteplase 0,25mg/Kg

Question 4

How long after IV thrombolysis should antithrombotic treatment start?

Answer 4

24h after

Question 5

What is the age limit for IV thrombolysis?

Is multimorbidity, prior disability or frailty a limitation?

Answer 5

Age is not a limit factor for IV thrombolysis

Patients with multimorbidity, frailty or prior disability (if there is no contraindication) can be benefited by treatment with IV thrombolysis

Question 6

Disabling minor ischemic stroke management

• Define “minor” and “disabling”

Answer 6

Disabling minor strokes should recieve treatment with IV alteplase

Minor = NIHSS<5
Disabling = a deficit that, if unchanged, would prevent the patient from performing basic activities of daily living (i.e., bathing, ambulating, toileting, hygiene, and eating) or returning to work

Question 7

Non-disabling minor ischemic stroke management

Answer 7

Patients with non-disabling minor stroke should not receive treatment with IV alteplase

** The only exception (expert opinion): patients with non-disabling minor stroke and large-vessel occlusion

Question 8

Rapidly improving symptoms but still disabling <4,5 hours duration

Answer 8

Thrombolysis with IV alteplase is sugested (expert opinion)

Question 9

i) clinically severe acute ischaemic stroke <4,5hours
and
ii) severe stroke with early ischaemic changes on CT <4,5hours management

• define severe stroke

Answer 9

Clinical severe stroke can be defined as NIHSS>25
CT imaging severe stroke can be defined as ASPECTS<7 or more than 1/3 of middle cerebral artery territory visible infarcion

i) Patients with severe acute ischemic stroke <4,5 hours –> thrombolysis with IV alteplase
ii) severe ischaemic stroke with early scanges on CT <4,5 hours –> thrombolysis with IV alteplase IN SELECTED CASES

Patient selection criteria might include

• eligibility for an alternative reperfusion strategy (mechanical thrombectomy)
• results of advanced imaging (notably core/perfusion mismatch)
• time since symptom onset
• extent of white matter lesions
• other contraindications for IVT
• pre-stroke disability

Question 10

Optimal blood pressure level for IV thrombolysis

Answer 10

Systolic blood pressure <185mmHg

Diastolic blood pressure <110mmHg

Question 11

Should treatment with IV alteplase be administered when blood glucose levels are >400mg/dL?

Answer 11

IV thrombolysis with alteplase should be performed

At the same time insulin therapy should be given to lower blood glucose levels

Question 12

Can patients with ischemic stroke who used antiplatelets prior to ischemic stroke receive treatment with IV alteplase?

Answer 12

Patients who used single or dual antiplatelet agents prior to the stroke can receive IV alteplase

Question 13

Can patients with ischemic stroke who used vitamin K antagonists before stroke receive treatment with IV alteplase?

Answer 13

Patients who use vitamin K antagonist can rceive treament with IV alteplase only if INR is <1,7

If INR is >1,7 or the result of coagulation testing is unknown they should not receive treatment with IV alteplase

Question 14

Can patients with ischemic stroke who use NOACs receive treatment with IV alteplase?

Answer 14

Patients who have used NOACs 48h prior to stroke cannot receive treatment with IV alteplase

The ecxeption are if:
Patients receiving factor Xa inhibitors have an anti-Xa activity <0,5 U/ml
Patients receiving direct thrombin inhibitors have a thrombin time <60s (expert opinion)
Patients using dabigatran can receive a combination of idarucizumab with IV alteplase

Question 15

What is the optimal platelet count to receive treatment with IV alteplase?

Answer 15

Platelet count should be >100

• If there the result is not known but there is no reason to expect abnormal values, treatment with IV alteplase should be administered

Question 16

Can patients with ischemic stroke and recent significant trauma, major surgery or biopsy receive treatment with IV alteplase?

• define major surgery

Answer 16

Significant trauma within the last three months is a contraindication for IV alteplase

Major surgery within 14 days, which can be defined as surgery of the abdomen, chest, skull or well-vascularized tissues or of any large artery is a contraindication for IV alteplase

Question 17

Can patients with ischemic stroke and a history of intracranial henorrhage receive tretment with IV alteplase?

Answer 17

Treatment with IV alteplase in patients with a history of intracerebral hemorrhage can be administered in selected cases e.g.

If a long time has passed since hemorrhage
If there was a specific underlying cause (trauma, subarachnoid haemorrhage with aneurysm removal, use of specific antithrombotic medication)

Question 18

Can patients with ischemic stroke and microbleeds receive treatment with IV alteplase?

Answer 18

If the presence of microbleeds is unknown or the burden is low (<10) patients can receive treatment with IV alteplase

Otherwise, it is a contraindication

Question 19

Can patients with ischmic stroke and cerebral white matter lesions receive treatment with IV alteplase?

Answer 19

Cerebral white matter lesions IS NOT a contraindication for treatment with IV alteplase

Question 20

Can patients with ischemic stroke and an unruptured cerebral aneurysm receive treatment with IV alteplase?

Answer 20

An unruptured cerebral artery aneurysm IS NOT a contraindication for treatment with IV alteplase

Question 21

Can patients with ischemic stroke and a history of ischemic stroke in the last 3 months receive treatment with IV alteplase?

Answer 21

Treatment with IV alteplase can be administered in patients with a history of ischemic stroke in selected cases e.g.

• small infarct
• > 1 month earlier
• good clinical recovery

Question 22

Can patients with ischemic stroke and a seizure at stroke onset receive treatment with IV alteplase?

Answer 22

Patients with a seizure at stroke onset can receive treatment with IV alteplase IF there is no suspicion of stroke mimic or significant head trauma

Question 23

Can patients with ischemic stroke and dissection receive treatment with IV alteplase?

Answer 23

It depends on the location

Patients with aortic arch dissection cannot receive treatment with IV alteplase

Patients with isolated cervical artery dissection can receive treatment with IV alteplase

Patients with intracerebral artery dissection cannot receive treatment with IV alteplase (expert opinion)

Question 24

Can patients with stroke and myocardial infarction receive treatment with IV alteplase?

Answer 24

It depends on the type of infarction

Patients with subacute >6h ST-elevation during the last seven days cannot receive treatment with IV alteplase

Patients with a history of non-ST-elevation during the last 3 months can receive treatment with IV alteplase

Patients with ST-elevation myocardial infarction >7 days to 3 months can receive IV alteplase depending on the size of myocardial infarction, whether recanalazation therapy was given, and echocardiographic findings (expert opinion)

Question 25

Can patients with ischemic stroke and infective endocarditis receive treatment with IV alteplase?

Answer 25

Patients with clear or suspected infective endocarditis cannot receive treatment with IV alteplase