Ischemic stroke management (based on Sinai protocol)

Labs: FS, electrolytes, CBC, coags, cardiac enzymes

Radiology: CT head

Indications for tPA: ischemic stroke, definite time of onset, NIHSS>1, no hemorrhage on head CT, onset of symptoms within 3 hours (4.5 hours in select patients)

Contraindications to tPA: thrombolytics given prior to arrival, SBP > 185 or DBP >110 despite treatment, history of ICH, brain aneurysm, AVM or brain tumor, intracranial or spinal surgery/head trauma/MI within the last 3 months, GI or GU hemorrhage within last 21 days, major surgery or trauma within the last 14 days, LP or arterial puncture at a non-compressible site within the last 7 days, platelets <100K, PTT not within normal range after dabigatran or IV heparin use, INR > or = 1.7, or other known bleeding diathesis, suspicion of SAH by imaging or clinical presentation

Relative contraindications to tPA: witnessed seizure at onset, FS >400, FS <50, increased risk of bleeding due to comorbid conditions, rapidly resolving neurological deficits, stroke severity to mild

IV tPA if indicated then give tPA(this is becoming controversial but currently is still given at Elmhurst and Sinai if meet inclusion criteria), if SBP>185 or DBP>110 then given labetalol/nicardipine push to see if can lower to appropriate range to give  tPA if BP successfully lowered, then keep SBP <185 and DBP <110

Not tPA candidate then BP control: if SBP<220 or DBP <120, then observe for end organ involvement, if SBP>220 or DBP >120, then use blood pressure lowering agents (ie. Labetalol or nicardipine) with 10 to 15% reduction in BP

May 2024