Last known normal <3 hr

Sudden onset of

Verifiable Neuro deficit, such as

  • Speech problem
  • Visual field loss
  • Unilateral weakness
  • Ataxia

Patient may be a TPA candidate

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NIHSS: Normal=0

  • LOC: 0-3
  • Speech
    • 2 questions: 0-2
    • 2 commands: 0-2
    • Dysarthria: 0-2
    • Aphasia: 0-3
  • Gaze: 0-2
  • Motor each limb: 0-4
  • Ataxia: 0-2
  • Sensory: 0-2
  • Extinction/Neglect: 0-2
Go to NIH Stroke Scale Form

Exclusion criteria

  • Significant head trauma or prior stroke in past 3 months
  • Symptoms suggest subarachnoid bleed
  • Arterial puncture at non-compressible site in past 7 days
  • History of intracranial hemorrhage
  • Intracranial neoplasm, AVM or aneurysm
  • Recent intracranial or intraspinal surgery
  • Elevated BP > 185/110 mm Hg)
  • Active internal bleeding
  • More Exclusion criteria

Exclusion criteria (Cont)

  • Acute bleeding diathesis, such as Platelet <100k/mm≥
  • Heparin received within 48 hours, with aPTT > upper limit
  • Current use of anticoagulant with INR > 1.7 or PT >15; seconds
  • Current use of NOAC
  • Blood glucose < 50 mg/dL
  • CT shows multilobar infarct (hypodensity > 1/3 cerebral hemisphere)

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No tpa if

  • Recent noac
  • Coagulopathy (plts <100k, inr>1.7, aPTT>40, or PT>15)
  • Infective endocarditis
  • Intra cranial, spine surgery <3 months
  • Recent GI/GU bleed within 3 weeks
  • Extensive low density area on CT
  • Suspected Subarachnoid Hemorrhage
  • Suspected aortic dissection
  • Hx of sickle cell disease

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Final check

tPA dose

Last known normal

3 to 4.5 hours

No tpa

If any of the following

  • over 80 years old
  • taking oral anticoagulant
  • NIHSS > 25
  • Preious Stroke plus Diabetes

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Post TPA

first 24 hours

  • No antiplatelet, anticoagulant for 24 hours
  • Bed rest
  • Keep BP <180/105
  • Avoid arterial puncture, Foley, NG
  • VTE prophylaxis with SCD
  • CT or MRI at 24 hour post tpa, check for bleed
  • Document stroke type.

TPA not given

  • Docuement reason why tpa not given. Example:
    • Past time window
    • Time last known normal not clear
  • Document stroke etiology.
  • Give Aspirin 325 mg po or 300 mg per rectal
  • Permissive Hypertension systolic up to 210
  • If creatinine ok, get CTA head and neck
  • Bed rest, VTE/DVT prophylaxis
  • Lipid in am, high intensity statin if needed
  • If atrial fibrillation, consider anticoagulation. Document reason if not started.
  • ST, OT, PT
  • Rehab, document if not needed

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NOAC

Do not use if

  • pregnancy
  • prosthetic valves

Choices

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Pradaxa (Dabigatran)

Direct Thrombin inhibitor = DTI

  • 150 mg bid
  • 110 mg bid: if age over 75, or high risk of bleeding
  • 75 mg bid: if CCr 15-50
  • Notes: no interaction with cytochrome
  • Dyspepsia 11%
  • tab break down with moisture

Eliquis (Apixaban)

  • 5 mg bid
  • 2.5 mg bid, if 2 of following:
    • over age 80
    • Creat over 1.5
    • weight <60 kg
  • 5 mg bid for end stage renal disease
  • minimal interaction with cytochrome
  • 25% excreted renal

Xarelto (Rivoxaban)

  • 20 mg qd w evening meal, CrCl >50
  • 15 mg qd: crcl > 15
  • Not recommended, if CrCl <15 or esrd
  • Notes: do not use Dilantin, Tegretol, antifungal
  • do not use in liver disease
  • more interaction with cytochrome

Atrial fibrillation: Treatment options

  • Stable coronary artery disease: NOAC
  • ACS, PCI, stents: NOAC reduced dose with triple therapy
  • Mechanical, rheumatic valve: VKA
  • TTR > 70 % on Warfarin: Continue VKA
  • CHA2DS2VASc=1: Dabigatrin, apixaban
  • On verapamil: reduce dose of dabigatran, edoxaban
  • On dronedrone (Multaq): reduce dose of edoxaban, dabigatran contrindicated, take with care on rivaroxaban, apixaban
  • Cont..

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Atrial fibrillation: Treatment options, Cont
  • Prior TIA, stroke: NOAC, avoid combine with asa
  • High risk GI bleed: Apixaban 5 mg, Dabigatran 110 mg
  • Renal impairment: Apixan 5 mg, apixaban 2.5 mg, rivaroban 15 mg

acs= acute coronary syndrome. pci=percutaneous coronary intervention. ttr=percent time in therapeutic range. VKA= vitamin K antigonist.

Source: modified from Diener HC, et al. Eur Heart J. 2016

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Document stroke etiology, required

  • Large artery atherosclerosis
  • Cardiac embolism
  • Small Vessel disease
  • Other determined etiology
    • dissection
    • Hypercoagulability
    • Other
  • Cryptogenic Stroke
    • Multiple potential etiologies
    • Undetermined etiology
    • Unspecified

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