IV tPA for acute ischemic stroke

Management of Stroke in the Neurocritical Care Unit

PURPOSE OF REVIEW

This article provides updated information regarding the diagnosis and treatment (specifically critical care management) of acute ischemic stroke. This article also discusses the increased use of thrombolysis and thrombectomy in clinical practice.

RECENT FINDINGS

Stroke is the leading cause of disability in the United States. A significant proportion of patients with acute ischemic stroke require critical care management. Much has changed in the early evaluation and treatment of patients presenting with acute ischemic stroke. The introduction of embolectomy in large vessel occlusions for up to 24 hours post-symptom onset has resulted in one in every three eligible patients with acute ischemic stroke with the potential to lead an independent lifestyle. These patients increasingly require recognition of complications and initiation of appropriate interventions as well as earlier admission to dedicated neurocritical care units to ensure better outcomes.

SUMMARY

This article emphasizes issues related to the management of patients with acute ischemic stroke undergoing mechanical thrombectomy and thrombolysis and addresses the complex physiologic changes affecting neurologic and other organ systems.

Treatment Delays for Patients With Acute Ischemic Stroke in an Iranian Emergency Department: A Retrospective Chart Review

STUDY OBJECTIVE

We evaluate the extent and nature of treatment delays and the contributing factors influencing them for patients with acute ischemic stroke, as well as main barriers to stroke care in an Iranian emergency department (ED).

METHODS

A retrospective chart review was conducted on 394 patients with acute ischemic stroke who were referred to the ED of a tertiary academic medical center in northwest Iran from March 21 to June 21, 2017. The steps of this review process included instrument development, medical records retrieval, data extraction, and data verification. Primary outcomes were identified treatment delays and causes of loss of eligibility for intravenous recombinant tissue plasminogen activator (r-tPA).

RESULTS

Of patients with acute ischemic stroke, 80.2% did not meet intravenous r-tPA eligibility; the most common cause was delayed (>4.5 hours) ED arrival after symptom onset (71.82%; n=283). Of 19.8% of subjects for whom the stroke code was activated, intravenous r-tPA was administered in only 5.3%. The average time from patients' arrival to first emergency medicine resident visit, notification of acute stroke team, presence of neurology resident, and computed tomography scan interpretation was lower for patients who met criteria of intravenous r-tPA than for those who lost eligibility for fibrinolytic therapy. The average door-to-needle time was 69 minutes (interquartile range 46 to 91 minutes).

CONCLUSION

Our ED and acute stroke team had a favorable clinical performance meeting established critical time goals of inhospital care for potentially eligible patients, but a poor clinical performance for the majority of patients who were not candidates for fibrinolytic therapy.