Acute Ischemic Stroke – Spoon-Feed Version

Written by Alex Chen, MD

Spoon Feed
No matter what you think about tPA (alteplase), this is a quick clinical practice summary to consider when you are taking care of your next stroke patient.

Why does this matter?
Stroke is common; 700,000 ischemic strokes occur in the U.S. each year. Thrombolytics and mechanical thrombectomy have opened up new, and sometimes, controversial treatments for stroke. Let’s see how this NEJM author summed this up.

Stroke step-by-step

1. Opening gambit: ABCs, check glucose

2. Determine: Time of onset (last known normal, LKN), NIHSS (NIH stroke scale), pre-morbid function (modified Rankin Scale, mRS)

3. Initial imaging of choice: CT head non-contrast to rule out bleed and calculate ASPECTS score.

4. Time from onset: 0-6 hours

   1. Disabling stroke (NIHSS ≥ 6) and within 4.5h -> IV tPA if eligible

      1. Get CTA/MRA if you have the capability. If unable, transfer to a facility with capability to perform mechanical thrombectomy.

   2. If ineligible for tPA – consider potential mechanical thrombectomy (NIHSS ≥ 6, ASPECTS ≥ 6).

   3. Give tPA if eligible, even if mechanical thrombectomy is still under consideration

5. Time from onset: 6-24 hours

   1. Perform CTA or MRA for potential thrombectomy if they meet either of the following.

      1. DEFUSE 3 Criteria: NIHSS ≥ 6; LKN between 6-16h; internal carotid or proximal middle cerebral artery (MCA) occlusion; infarct volume <70 mL, ratio of ischemic tissue to initial infarct volume ≥1.8, and absolute volume of penumbra ≥15mL on CT perfusion or MRI diffusion/perfusion.

      2. DAWN Criteria: LKN between 6-24h; internal carotid or first segment MCA; clinical deficits greater than infarct volume: ≥80 y NIHSS ≥10 and infarct <21mL OR <80y NIHSS ≥10 and infarct <31mL OR <80y NIHSS ≥20 and infarct 31 to <51mL.

6. For patients who do not fit in the previous criteria

   1. < 24 hours

      1. NIHSS ≤ 3

         1. 21 day course of clopidogrel + aspirin (if no contraindications) within 24h of onset

   2. > 24 hours

      1. Daily aspirin (if no contraindications) within 48h of onset

7. Considerations

   1. There may be a role for tPA at 4.5-9h if thrombectomy is unavailable and there is a large penumbra to core ratio (> 1.2, infarct core volume < 70mL) on CT perfusion study or MR perfusion.

Source
Acute Ischemic Stroke. N Engl J Med. 2020 Jul 16;383(3):252-260. doi: 10.1056/NEJMcp1917030. 

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