Stroke

Question 1

What factors limit TPA use in 3-4.5 hour window? Why do these parameters exist?

Answer 1

> 80 years
NIHSS >25
Any use of anticoagulation regardless of INR/PT/aPTT
Previous stroke and diabetes

These were exclusion criteria for the trials done showing benefit in 3-4.5 hour window. TPA may in fact be safe and beneficial for these patients. We do not yet know.

Question 2

Blood pressure goal for TPA?

Answer 2

<185/110

Question 3

Platelet threshold for TPA?

Answer 3

<100,000

Question 4

Can patient on Warfarin get TPA?

Answer 4

If INR<1.7

Question 5

Can patient on Xa inhibitor get TPA?

Answer 5

Not within 48 hours of taking medication with normal renal function

Question 6

What previous history precludes TPA use?

Answer 6

Stroke or severe head trauma in 3 months
Previous brain bleed ever
Brain cancer
GI cancer
GI bleed in last 21 days
Brain or spine surgery in last 3 months

Question 7

Patient recently on heparin, can they have TPA?

Answer 7

No TPA if THERAPEUTIC heparin within 24 hours
Yes TPA if prophylactic heparin

Question 8

Is TPA used if thrombectomy is planned?

Answer 8

Yes

Question 9

What head CT findings preclude TPA?

Answer 9

Hemorrhage
Large hypodense area that suggest irreversible injury

Question 10

Patient with stroke and endocarditis. Is TPA given?

Answer 10

No TPA with endocarditis associated stroke

Question 11

Can TPA be given in pregnancy?

Answer 11

Yes, if benefits felt to outweigh risks of increased uterine bleeding

Question 12

Patient with remote GI bleeding, can give TPA?

Answer 12

Relative contraindication when >21 days since GI or GU bleed

Question 13

Patient had seizure at onset of stroke and is post-ictal with residual impairments. Is TPA given?

Answer 13

Relative contraindication
Can give if you feel that impairments are from stroke and not from post-ictal state. Hard choice.

Question 14

Patient has an untreated 5mm intracranial aneurysm. Can TPA be given?

Answer 14

Recommendations say that >10mm becomes a relative contraindication, but safety is unclear for this scenario.W

Question 15

What guidelines are there for TPA and recent trauma or surgery?

Answer 15

Relative contraindication for severe trauma or major surgery within 14 days

Question 16

Should you wait for labs to give TPA?

Answer 16

No
Get labs if high suspicion for platelets being low, if currently on a blood thinner, or if blood thinner use is unknown

Question 17

What are the PT/aPTT limits for TPA?

Answer 17

PT >15 seconds
aPTT>40 seconds