Professor Wang Yongjun: Screening of suitable people for intravenous thrombolytic therapy for ischemic stroke (both charts are all done!)

*Only for medical professionals to refer to and read the clinical specifications, high-quality recommendation! Intravenous thrombolytic therapy is an important measure for reperfusion therapy after the onset of ischemic stroke.
Recombinant tissue-type plasminogen activator (r‑tPA) is the most evidenced and most widely used intravenous thrombolytic drug
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Screening patients suitable for intravenous thrombolysis with r‑tPA is the key to successful intravenous thrombolysis
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This article discusses how to screen out r‑tPA suitable for intravenous thrombolysis from various aspects such as intravenous thrombolysis time window, age, mild stroke, multiple diseases or concurrent multiple conditions, recent puncture/surgery/trauma, and previous antithrombotic drugs.
The crowd
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Indications: It is recommended that intravenous r‑tPA thrombolysis (0.
9 mg/kg, maximum dose 90 mg, 10% bolus injection for 1 min, and use up of the remaining 60 min) within 3 hours for careful screening of symptoms or appearance Patients with ischemic stroke who were normal or who finally appeared to be within 3 hours of baseline
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Clinicians should refer to this table to determine whether the patient is suitable for thrombolysis
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Age within 3 h For patients ≥ 18 years of age, if other aspects are suitable for intravenous r-tPA thrombolysis within 3 h, then patients are equally suitable for thrombolysis regardless of whether they are ≤ 80 years old or> 80 years old
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Severe stroke within 3 hours When the stroke symptoms are severe, intravenous r‑tPA thrombolysis can be used for patients with ischemic stroke within 3 hours of the onset of symptoms
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Despite the increased risk of hemorrhagic transformation, the clinical benefit of patients with severe stroke symptoms has been confirmed
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Mild disabling stroke within 3 hours When stroke symptoms are mild but disabling, intravenous r‑tPA thrombolysis can be used for patients with ischemic stroke within 3 hours of onset of symptoms
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Patients with mild but disabling stroke symptoms cannot be excluded from intravenous r‑tPA thrombolysis because the clinical benefits of such patients have been confirmed
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It is also recommended to use intravenous r‑tPA thrombolysis (0.
9 mg/kg, maximum dose 90 mg, 10% bolus injection for 1 minute, and use up the remaining 60 minutes) for careful screening of symptoms that appear or finally look normal 3~4.
5 h3 Patients with ischemic stroke between ~4.
5 hours
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It is recommended to use intravenous r-tPA thrombolysis between 3 and 4.
5 hours for the age of 3 to 4.
5 hours for patients ≤80 years of age, with diabetes and previous stroke at different times, NIHSS ≤25 points, currently not taking oral anticoagulants, and lack of imaging studies.
Patients whose blood damage area is not more than 1/3 of the MCA basin
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Urgency Within the above-mentioned time window, thrombolysis should be implemented as soon as possible
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Because the treatment time has a strong correlation with the outcome
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Blood pressure recommends that intravenous r‑tPA thrombolysis is used for those whose blood pressure can be safely reduced by antihypertensive drugs (to <185/110 mmHg)
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Physicians should evaluate the stability of blood pressure before initiating intravenous r‑tPA thrombolytic therapy
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Blood glucose It is recommended to use intravenous r‑tPA thrombolysis for patients with initial blood glucose >50 mg/dl (2.
8 mmol/L) and other aspects are suitable for thrombolysis
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CT recommends intravenous r-tPA thrombolysis for patients with small to moderate early ischemic changes on plain CT (not significantly low density)
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Previous antiplatelet therapy recommends intravenous r-tPA thrombolysis for those who are taking antiplatelet monotherapy before stroke
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Because there is evidence that the benefit of thrombolysis outweighs the slightly increased risk of symptomatic cerebral hemorrhage; it is recommended that intravenous r‑tPA thrombolysis be used for those who are taking antiplatelet therapy before stroke (for example, aspirin + clopidogrel)
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Because there is evidence that the benefits of thrombolysis outweigh the potentially increased risk of symptomatic cerebral hemorrhage
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For end-stage renal disease patients undergoing dialysis, if aPTT is normal, intravenous r‑tPA is recommended for thrombolysis
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If aPTT is elevated, the risk of bleeding complications increases
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Other recommendations are that for patients older than 80 years of age from 3 to 4.
5 hours, intravenous r-tPA thrombolysis is as safe and effective as younger patients within the window of 3 to 4.
5 hours
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3-4.
5 h diabetes and past stroke have both diabetes and past stroke history.
In the 3-4.
5 h window, intravenous r-tPA thrombolysis may be as effective as the 0-3 h window in young patients, and may be a reasonable choice
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Severe strokes from 3 to 4.
5 hours with very severe stroke symptoms (NIHSS> 25 points), the benefit of intravenous r-tPA thrombolysis within the window of 3 to 4.
5 hours is not clear
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3~4.
5 h mild disabling stroke For patients with mild disabling stroke, if other aspects are suitable for thrombolysis, intravenous thrombolysis within 3~4.
5 h after the onset may be reasonable
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Stroke after awakening and stroke with unknown onset time For patients with acute ischemic stroke who have a stroke after waking up or whose onset time is unknown> 4.
5 hours from the last normal/baseline state, if the DWI lesion is <1/3 of the middle cerebral artery basin and FLAIR is not seen If the signal changes, it is reasonable to give intravenous r-tPA thrombolysis (0.
9 mg/kg, maximum dose 90 mg, 10% bolus injection for 1 min, and use up the remaining 60 min) within 4.
5 hours after symptoms are found
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Pre-existing disability Pre-existing disability may not independently increase the risk of symptomatic cerebral hemorrhage caused by intravenous r‑tPA thrombolysis, but there is less improvement in neurological function and higher mortality
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For people with existing disabilities (mRS ≥ 2 points), intravenous r‑tPA thrombolysis may be reasonable, but relevant factors should be considered when making decisions, including quality of life, social support, place of residence, care needs, patient and family values, and treatment Target: People with pre-existing dementia may benefit from intravenous r‑tPA thrombolysis
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Life expectancy and pre-onset functional level should be considered in decision-making to assess whether r-tPA can bring clinically meaningful benefits
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Early improvement of patients with moderate to severe ischemic stroke, early improvement but still moderate neurological deficits and the examiner believes that it may be disabled, intravenous r‑tPA thrombolysis is reasonable
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Epileptic seizures occur during the onset of seizures.
If there is evidence that the residual symptoms are caused by stroke rather than post-seizure phenomena, intravenous r-tPA thrombolysis is reasonable
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For patients with initial blood glucose <50 mg/dl (2.
8 mmol/L) or >400 mg/dl (22.
2 mmol/L), if other aspects are suitable for thrombolysis, after correction, intravenous r‑tPA thrombolysis may be reasonable
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For coagulopathy with a history of warfarin use and INR≤1.
7 and/or PT<15 s, intravenous r‑tPA thrombolysis may be reasonable; for patients with a history of potential hemorrhagic diathesis or coagulopathy, the effectiveness of intravenous r‑tPA thrombolysis And the security is unknown
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Intravenous r-tPA thrombolysis can be considered individually
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For patients who have received lumbar puncture within 7 days after dural puncture, intravenous r‑tPA thrombolysis can be considered
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The safety and effectiveness of intravenous r-tPA thrombolysis in patients who have undergone arterial puncture within 7 days of arterial puncture on non-compressible blood vessels are uncertain
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For those who have had serious trauma without involving the head within the past 14 days, intravenous r-tPA thrombolysis can be carefully considered
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The risk of bleeding caused by trauma needs to be weighed against the severity of ischemic stroke and potential disability
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For those who have undergone major surgery within 14 days of recent major surgery, intravenous r-tPA thrombolysis can be considered carefully
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The risk of bleeding at the surgical site needs to be weighed against the expected benefit of reducing neurological deficits
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Gastrointestinal and genitourinary tract bleeding For patients with previous gastrointestinal/genitourinary tract bleeding, the literature reports that the risk of bleeding from intravenous r‑tPA thrombolysis is low
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It may be reasonable for such patients to receive intravenous r‑tPA thrombolytic therapy
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(Gastrointestinal bleeding within 21 days is not recommended
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See Contraindications) For women with menstruation and menstrual periods, intravenous r‑tPA thrombolysis is likely to be suitable
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However, it should be reminded for women that r-tPA treatment may increase menstrual bleeding.
For those with recent or active vaginal bleeding, if there is significant anemia, they may need to seek emergency consultation with a gynecologist before deciding on intravenous r-tPA thrombolytic therapy; in the near future; If there is a history of active menorrhagia, if there is no obvious anemia or hypotension, intravenous r-tPA thrombolysis can be considered, because the potential benefits may exceed the risk of severe bleeding
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Extracranial carotid artery dissection is known or suspected of acute ischemic stroke related to extracranial carotid artery dissection, intravenous r-tPA thrombolysis is safe within the 4.
5-hour window, and it is likely to be recommended
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In patients with intracranial artery dissection known or suspected that acute ischemic stroke is related to intracranial artery dissection, the usefulness and bleeding risk of intravenous r-tPA thrombolysis are unknown, uncertain, and unproven
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For unruptured intracranial aneurysms with small or medium size (<10 mm) unruptured and untreated intracranial aneurysms, intravenous r‑tPA thrombolysis is reasonable and is likely to be recommended; there are large unruptured and untreated intracranial aneurysms.
In patients with internal aneurysms, the usefulness and risk of intravenous r‑tPA thrombolysis have not been proven
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Intracranial vascular malformations have unruptured and untreated intracranial vascular malformations, the usefulness and risk of intravenous r‑tPA thrombolysis has not been proven; because such patients have a high risk of cerebral hemorrhage, intravenous r‑tPA thrombolysis can be considered for patients with intracranial vascular malformations.
Stroke patients with severe neurological impairment and a high risk of disability and death, these risks exceed the risk of cerebral hemorrhage caused by thrombolysis
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Cerebral microhemorrhage.
Previous MRI showed a small amount (1-10) of microbleeds.
If other aspects are suitable for thrombolysis, intravenous r‑tPA thrombolysis is reasonable; previous MRI showed a large number (>10) of microbleeds, If other aspects are suitable for thrombolysis, the risk of symptomatic cerebral hemorrhage due to intravenous r‑tPA thrombolysis is increased, and the benefit of thrombolysis is uncertain
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If there is a possibility of obvious benefit, thrombolysis is reasonable
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Combination of tirofiban and eptifibatide intravenous glycoprotein IIb/IIIa inhibitors tirofiban and eptifibatide together with intravenous r-tPA thrombolysis is still uncertain
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For patients with extraaxial intracranial tumors, intravenous r‑tPA thrombolysis is likely to be recommended
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In patients with acute myocardial infarction, both acute ischemic stroke and acute myocardial infarction are given intravenous r‑tPA thrombolysis according to the cerebral ischemic dose
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If indicated, it is reasonable to follow percutaneous coronary angioplasty or stent implantation
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Patients with recent myocardial infarction in the past 3 months with a history of myocardial infarction, if the myocardial infarction is non-STEMI, intravenous r‑tPA thrombolytic therapy for ischemic stroke is reasonable; patients with a history of myocardial infarction in the past 3 months, if the myocardial infarction is right For STEMI of the lateral or inferior myocardium, intravenous r‑tPA thrombolysis is reasonable for the treatment of ischemic stroke; for patients with a history of myocardial infarction in the past 3 months, if the myocardial infarction is STEMI that affects the left anterior myocardium, intravenous r‑tPA dissolves Suppository treatment is reasonable for ischemic stroke
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Acute pericarditis is likely to lead to severe acute ischemic stroke with severe disability.
In the case of acute pericarditis, intravenous r‑tPA thrombolysis may be reasonable
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Urgent consultation with a cardiologist is recommended; moderate acute ischemic stroke that is likely to cause mild disability, such as acute pericarditis, the net benefit of intravenous r‑tPA thrombolysis is uncertain
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Left atrial or left ventricular thrombosis is likely to cause severe acute ischemic stroke with severe disability.
If left atrial or left ventricular thrombosis is known, intravenous r‑tPA thrombolysis may be reasonable; it is likely to cause moderate disability In acute ischemic stroke, if left atrial or left ventricular thrombosis is known, the net benefit of intravenous r‑tPA thrombolysis is uncertain
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Other severe acute ischemic strokes that are likely to cause severe disability due to other heart diseases.
In the case of cardiac myxoma, intravenous r‑tPA thrombolysis may be reasonable; severe acute ischemic strokes that are likely to cause severe disability, such as papillary For elastin fibroids, intravenous r‑tPA thrombolysis may be reasonable
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Stroke after operation If acute ischemic stroke is a complication of cardiac or cerebral angiography, intravenous r-tPA thrombolysis is reasonable, refer to the common screening criteria
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For systemic malignancies who currently have malignant tumors, the effectiveness and safety of r-tPA have not been proven
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When there is a systemic malignant tumor and a reasonable life expectancy (>6 months) and other contraindications (such as abnormal coagulation, recent surgery, systemic bleeding) do not exist, it is possible to benefit from intravenous r‑tPA thrombolysis
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For pregnant patients with moderate or severe stroke, the expected benefit exceeds the increased risk of uterine bleeding, intravenous r‑tPA thrombolysis can be considered; early postpartum (<14 days after delivery), the safety and safety of intravenous r‑tPA thrombolysis The effectiveness has not been proven
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For those with a history of diabetic hemorrhagic retinopathy or other hemorrhagic eye diseases, the suggestion of intravenous r‑tPA thrombolysis is reasonable, but the potential risk of vision loss must be weighed against the expected benefits of reducing stroke symptoms
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For sickle cell disease in adults with acute ischemic stroke who are known to have sickle cell disease, intravenous r‑tPA is beneficial for thrombolysis
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MCA high-density syndrome For patients with MCA high-density syndrome, intravenous r‑tPA is beneficial for thrombolysis
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Drug addicts should understand that drugs are one of the causes of cryptogenic stroke
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If the acute ischemic stroke is related to drug use and there are no other contraindications, intravenous r‑tPA thrombolysis is reasonable
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The risk of symptomatic intracranial hemorrhage is very low in the group of patients with stroke simulation disease
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It is likely that the initiation of intravenous r‑tPA thrombolysis should be preferred over the postponement of treatment for more diagnostic tests
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Contraindications: 0~3 h mild non-disabling stroke is suitable for other stroke patients with mild symptoms (NIHSS 0~5 points) and non-disabling stroke patients.
When symptoms appear or within 3 hours from the last normal or baseline state, no Intravenous r‑tPA is recommended for thrombolysis
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3~4.
5 h mild non-disabling stroke is suitable for other stroke patients with mild symptoms (NIHSS 0~5 points) and non-disabling stroke.
It is not recommended when symptoms appear or within 3~4.
5 hours from the last normal or baseline state Intravenous r‑tPA thrombolysis
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CT does not have sufficient evidence to classify the threshold of the severity or scope of the effect of thrombolysis
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However, it is not recommended to use intravenous r-tPA thrombolysis for patients with large areas of apparent low density on CT
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Even if these patients undergo intravenous r‑tPA thrombolysis, the prognosis is poor
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Severely low density is obviously low density, meaning that the damage is irreversible
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Cerebral hemorrhage is not recommended for intravenous r‑tPA thrombolysis for patients with acute intracranial hemorrhage on CT
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Ischemic stroke within 3 months If you have had an ischemic stroke within 3 months, intravenous r‑tPA thrombolysis may be harmful
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Intravenous r‑tPA thrombolysis for severe head trauma within 3 months is contraindicated for those who have had severe head trauma within the past 3 months
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Acute head trauma, because severe head trauma increases the risk of bleeding complications, intravenous r‑tPA thrombolysis cannot be used for infarcts in the hospital after trauma that occurs in the acute stage of head trauma
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Intracranial/intraspinal canal surgery in the past 3 months If you have undergone intracranial/intraspinal surgery in the past 3 months, intravenous r‑tPA thrombolysis may be harmful
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For those with a history of intracranial hemorrhage, intravenous r‑tPA thrombolysis may be harmful
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Intravenous r‑tPA thrombolysis for subarachnoid hemorrhage is contraindicated in patients with symptoms and signs consistent with subarachnoid hemorrhage
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Gastrointestinal malignancies or gastrointestinal bleeding within 21 days Patients with gastrointestinal malignancies or gastrointestinal bleeding within 21 days should be considered high-risk, and intravenous r‑tPA thrombolysis may be harmful
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Intravenous r-tPA thrombolysis for coagulopathy is used for platelet counts <100000/mm3 (100×109/L), INR>1.
7, aPTT>40 s, or PT>15 s.
The safety and effectiveness are unknown and should not be used
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[If the patient has no history of thrombocytopenia, intravenous r‑tPA thrombolysis can be initiated before the platelet count is obtained; once the platelet count is less than 100000/mm3 (100×109/L), intravenous r‑tPA thrombolysis should be stopped
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If the patient has not recently used oral anticoagulants or heparin, intravenous r‑tPA thrombolysis can be initiated before the coagulation results are obtained; once the INR>1.
7 or the PT is abnormally elevated, intravenous r‑tPA thrombolysis should be stopped
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] Low-molecular-weight heparin intravenous r‑tPA thrombolysis should not be used for those who have received the full therapeutic dose (non-preventive dose) of low-molecular-weight heparin within the past 24 hours
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Thrombin inhibitors or factor Xa inhibitors who are taking direct thrombin inhibitors or factor Xa inhibitors, the effect of intravenous r-tPA on thrombolysis has not been confirmed, but it may be harmful
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Intravenous r‑tPA thrombolysis should not be used for people who are taking thrombin inhibitors or factor Xa inhibitors, unless the test results are normal (such as aPTT, INR, platelet count, ECT, TT, direct factor Xa activity determination), or the patient has not Take these anticoagulants for >48 hours (provided renal function is normal)
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Co-administration of abciximab Abiximab should not be used simultaneously with intravenous r‑tPA thrombolysis
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Combination of intravenous aspirin should not be given within 90 minutes after the start of intravenous r‑tPA thrombolysis
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Infective endocarditis If the patient’s symptoms are consistent with infective endocarditis, intravenous r‑tPA should not be used for thrombolysis because of the increased risk of intracranial hemorrhage
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If aortic arch dissection is known or suspected, intravenous r-tPA thrombolysis may be harmful and should not be used
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In patients with axial intracranial tumors, intravenous r‑tPA thrombolysis may be harmful
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Source of this article: Neurology Medical Network.
Review of this article: Li Tuming, Deputy Chief Physician Editor: Mr.
Lu Li Copyright Statement 】Hospital+Department+Name Contributions are in the form of word documents, and the remuneration is favorably edited.
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