based on intel

Question 1

List contraindications for tPA in STROKE

Answer 1

Brain:
Hemorrhagic transformation
Previous ICH
AVM
Brain cancer
Stroke within 3 mo
Closed head injury within 3 mo
CNS surgery within 2 mo

Hematologic:
OAC
Plt <100
INR >1.7
Heparin use

Other:
Arterial puncture non-compressible
Severe uncontrollable HTN
Glucose <2.8
Active bleeding
Bleeding diathesis

Question 2

What is the shock index?

Answer 2

HR/SBP
Normal is 0.5-0.7
over ~0.8 suggests significant instability and possible shock

Question 3

What are the basic eligibility criteria for tPA?

Answer 3

Eligibility for tPA

• Age ≥18
• Clinical diagnosis of ischemic stroke causing neurological deficit
• Time of symptom onset <4.5 hours

Question 4

What are the absolute contraindications to tPA?

Answer 4

• Intracranial hemorrhage on CT
• Clinical presentation suggests subarachnoid hemorrhage
• Neurosurgery, head trauma, or stroke in past 3 months
• Uncontrolled hypertension (>185 mmHg SBP or >110 mmHg DBP)
• History of intracranial hemorrhage
• Known intracranial arteriovenous malformation, neoplasm, or aneurysm
• Active internal bleeding
• Suspected/confirmed endocarditis
• Abnormal blood glucose (<50 mg/dL)
• Known bleeding diathesis

[ie, (1) Platelet count < 100,000; (2) Patient has received heparin within 48 hours and has an elevated aPTT (greater than upper limit of normal for laboratory); (3) Current use of oral anticoagulants (ex: warfarin) and INR >1.7; (4)Current use of direct thrombin inhibitors or direct factor Xa inhibitors]

Question 5

What are the relative contraindications to tPA?

Answer 5

• Only minor or rapidly improving stroke symptoms
• Major surgery or serious non-head trauma in the previous 14 days
• History of gastrointestinal or urinary tract hemorrhage within 21 days
• Seizure at stroke onset
• Recent arterial puncture at a noncompressible site
• Recent lumbar puncture
• Post myocardial infarction pericarditis
• Pregnancy

Question 6

What additional cautions are there re tPA?

Answer 6

If <4.5h but >3h:

• Age >80 years
• History of prior stroke and diabetes
• Any active anticoagulant use (even with INR <1.7)
• NIHSS >25
• CT shows multilobar infarction (hypodensity >1/3 cerebral hemisphere)