After a head CT scan has been performed and intracranial hemorrhage has been ruled out, an eligibility assessment should be performed. There are a number of inclusion and exclusion criteria for ensuring that fibrinolytic therapy is the best option.
Factors that must exist for the patient to receive fibrinolytic therapy are:
- The patient must be 18 years or older.
- The onset of symptoms must be less than 3 hours before beginning treatment.
- The stroke appears to be causing measurable neurologic deficit.
Factors that would exclude a patient from receiving fibrinolytic therapy are:
- Any evidence of active bleeding
- History of intracranial hemorrhage
- Symptoms suggest subarachnoid hemorrhage
- Head trauma or stroke in the past 3 months
- Elevated blood pressure (systolic > 185 mmHg or diastolic > 110 mmHg)
- Arterial puncture at a noncompressible site within the past 7 days
- Increased potential for bleeding related any disease process. This can include a platelet count <100,000/mm3, current use of anticoagulants with with INR>1.7 or PT > 15 seconds, or Heparin received within 48 hours which resulted in a aPTT greater than the upper normal limit.
- Blood glucose less than 50 mg/dL
- CT demonstrates multilobar infarction with hypodensity > 1/3 of the cerebral hemisphere.
If the patient meets all of the inclusion criteria and does not have any of the exclusion criteria, it is time to quickly move forward with thrombolytic therapy.
Adverse Side Effects
There is always a risk for potential adverse effects from the rtPA (fibrinolytic therapy). The most common side effects are intracranial hemorrhage, other forms of bleeding, angioedema and transient hypotension. In every stroke case, the patient’s risk for adverse effects has to be weighed against the potential benefit.
The stroke team should be prepared to intervene when adverse side effects occur.