Hospital Medicine

Post-tPA Stroke Management

Post-tPA Stroke Management

I. What every physician needs to know.

Not truly a separate disease state, this chapter is specific to the management of an ischemic stroke patient who has already received IV tPA (either in the ED or in the hospital) and now requires inpatient care. Patients with ischemic stroke who have received tPA must be treated differently than stroke patients who have not.

II. Diagnostic Confirmation: Are you sure your patient has Post-tPA Stroke?

This is straightforward as the confirmation that the patient had an acute ischemic stroke was hopefully made prior to the administration of IV tPA. Confirm that the patient received IV tPA and proceed with care. Certainly, the clinical diagnosis can be wrong and tPA can be given to patients not having an ischemic stroke (most common are conversion disorder or post-ictal Todd's paralysis), but in those patients the post-tPA management is actually less dangerous because there is almost no risk of intracranial bleeding in a patient with normal cerebral vasculature (assuming that is the case in the conversion and seizure patients).

A. History Part I: Pattern Recognition:

Again, this is not about recognizing acute stroke but about what to do to treat the patient that has received tPA.

B. History Part 2: Prevalence:

Nationally, only 10-20% of pristinely eligible (clear time of onset, no tPA contraindications, arrived well within the 3 hour window, etc) patients with an acute ischemic stroke actually receive IV tPA. But for those who receive IV tPA, it is felt that 90-95% of the complications (IV tPA's risk from the original trial is 6% risk of major hemorrhage/death) are either directly or indirectly related to mis-management during the first 24 hours after receiving IV tPA (thus the importance of this chapter).

C. History Part 3: Competing diagnoses that can mimic Post-tPA Stroke.

Again, this is not completely applicable as the diagnosis is (hopefully) made for you if the patient received tPA.

D. Physical Examination Findings.

This will vary depending on where the patient's stroke is, but from a post-tPA management standpoint, the key on exam is that you are looking for CHANGES in their neurologic exam. See examples below.

E. What diagnostic tests should be performed?

The only diagnostic test you may need is a STAT computed tomography (CT) head (without contrast) if there is a neurologic change and you suspect a hemorrhage.

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

There are no specific lab studies, but remember, there should be no arterial sticks and no venipuncture at non-compressible sites for the first 24 hours after tPA administration. If you think you might need these for whatever reason, do them before you give the tPA.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

As above, you may need a STAT head CT if the patient has precipitous neurologic decline. Assuming the patient is receiving the standard ischemic stroke work-up now that they are admitted for post-tPA management, then you would have magnetic resonance imaging (MRI) brain, MRA head/neck, echo, and carotid dopplers as choices for diagnostic imaging to look for the cause of the stroke that necessitated tPA administration.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

There is no need to do a follow-up CT head the following day just to "make sure" there is no hemorrhage from the tPA. Only get a new CT if the exam is worsening. The focus is managing clinically the patient who has received tPA, then working up why they had a stroke in the first place.

III. Default Management.

  1. BP Control

    1. Parameters for blood pressure are that BP must be strictly controlled toless than 180/105 for the first 24 hours after receiving tPA. Use prn labetalol 10-20mg IV or hydralazine 10-20mg IV initially and then drips (labetalol or nicardipine) if necessary to control the pressure (see protocol for BP treatment below in "Immediate Treatment." This is the critical management step as it is felt that almost all bleeding complications from tPA stem from failure to control BP after tPA administration.

    2. Blood pressure monitoring should be q15 minutes for 2 hours followed by q1 hour for the first 24 hours after tPA administration.

  2. Admission Protocol

    1. The patient needs to receive neuro checks every hour for the first 24 hours.

    2. Find the patient the appropriate bed to accommodate above frequent BP and neuro checks. This usually means that the patient will need to have an ICU bed (to receive that level of monitoring), but if your hospital can do vitals of that frequency in a step-down unit, then that works too.

    3. Head of bed should be kept between flat and 30 degrees (flatter is better, but if the patient cannot tolerate completely flat due to back problems or GERD, etc, then can elevate slightly up to 30 degrees max) for the first 24 hours.

    4. Defer starting antiplatelet therapy for 24 hours (BUT this also means that after 24 hours, you can safely start Aspirin/Plavix/Aggrenox/etc.)

    5. Use SCD's instead of chemical DVT prophylaxis for the first 24 hours, but you can switch to chemical prophylaxis after the first 24 hours.

    6. No arterial sticks or venipuncture of non-compressible sites in the first 24 hours.

    7. The patient should have other routine admission orders.

    8. After the first 24 hours, vitals and neuro checks can be changed back to more routine orders (after moving patient to a regular floor bed).

A. Immediate management.

The key emergent/immediage management isblood pressure control (must keep BP <180/105 for the entire 24 hour period after receiving tPA).

Protocol:

If Systolic greater than 185 OR diastolic greater than 110, then

  • Labetalol 10-20 mg IV over 1-2 min OR

  • Hydralazine 10-20 mg IV over 1-2 min

  • If still elevated, then

    • ◦ May repeat or double labetalol every 10 min to maximum dose of 300 mg

    • ◦ OR give initial labetalol dose, then start labetalol drip at 2-8 mg/min

    • ◦ OR give Nicardipine 5 mg/hr IV infusion as initial dose and titrate to desired effect by increasing 2.5 mg/hr every 5 min to maximum of 15 mg/hr

B. Physical Examination Tips to Guide Management.

If the tPA is working, then obviously the patient's weakness/numbness/etc should be improving. If the patient is starting to have a hemorrhage, the first signs are worsening of their existing neurologic deficit, followed by change in mental status.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

NA

D. Long-term management.

After the first 24 hours, there is essentially no difference in management from routine acute ischemic stroke care.

E. Common Pitfalls and Side-Effects of Management.

The key is thatunlike the "permissive hypertension" that is used in typical acute ischemic stroke management, if the patient received tPA, theyMUST have blood pressure aggressively controlled.

Preference isNOT to use nitrates as they will drop cerebral perfusion pressure (not what you want in the setting of an acute stroke).

Most people remember to hold antiplatelet and chemical DVT prophylaxis agent in patient who receives tPA, but don't forget torestart bothafter the first 24 hour period after receiving the tPA.

The above under "Default Management" can be used as an order set when added to routine acute ischemic stroke admission orders.

IV. Management with Co-Morbidities.

N/A

A. Renal Insufficiency.

No change in standard management.

B. Liver Insufficiency.

No change in standard management.

C. Systolic and Diastolic Heart Failure.

If having to use drips to control BP, then will need to watch for volume overload.

D. Coronary Artery Disease or Peripheral Vascular Disease.

No change in standard management.

E. Diabetes or other Endocrine issues.

No change in standard management.

F. Malignancy.

No change in standard management.

G. Immunosuppression (HIV, chronic steroids, etc).

No change in standard management.

H. Primary Lung Disease (COPD, Asthma, ILD).

No change in standard management.

I. Gastrointestinal or Nutrition Issues.

No change in standard management.

J. Hematologic or Coagulation Issues.

May have precluded patient receiving tPA in the first place.

K. Dementia or Psychiatric Illness/Treatment.

No change in standard management.

V. Transitions of Care.

A. Sign-out considerations While Hospitalized.

This is key as specifying differently that the patient has received tPA is very important. The unusual care orders should be highlighted:

  • Yes, you really do want q 1 hour blood pressure and neuro checks for the first 24 hours.

  • Spell out the need to keep BP <180/105, using the protocol for prn's and drips as described above.

  • Remind them no arterial sticks or venous sticks at non-compressible sites.

B. Anticipated Length of Stay.

Barring complication, receiving IV tPA should only add one day to the routine ischemic stroke admission. Plus if the tPA really worked well, it may dramatically shorten the admission because the patient may be able to be discharged home without needing inpatient rehab or other placement.

C. When is the Patient Ready for Discharge.

After the first 24 hours, the patient can be returned to usual care for acute ischemic strokes.

D. Arranging for Clinic Follow-up.

N/A

1. When should clinic follow up be arranged and with whom.

Follow-up should be with neurology, preferrably in a stroke clinic.

2. What tests should be conducted prior to discharge to enable best clinic first visit.

None

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

None

E. Placement Considerations.

Depends on resolution of stroke symptoms with tPA, can vary from back to baseline/home, home with outpatient therapy, home with home therapy, inpatient rehab, SNF, nursing home, etc.

F. Prognosis and Patient Counseling.

Prognosis is good if BP is controlled (per original trial, tPA gives 30% chance of little/no residual deficit at 3 months post-stroke but carries risk of 6% of major hemorrhage/death - remember that majority of that 6% risk hinges on BP control).

VI. Patient Safety and Quality Measures.

A. Core Indicator Standards and Documentation.

JCAHO indicators only around tPA being administered to appropriate candidates and to portions of care relevant to general acute ischemic stroke care and not specific to post-tPA management.

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

Modifying stroke risk factors like any other ischemic stroke admission (see Ischemic stroke chapter).

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