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Initial Assessment:
- Obtain Vitals and blood glucose level
- Time of onset (important for tPA/TNK vs thrombectomy)
- Neurologic and Cardiac Examination / NIHSS
- do not delay head CT to complete NIHSS, can always finish after CT
- Assess contraindications for tPA
Workup:
- Labs: CBC, CMP, Troponin, Coags, EtOH, bedside accucheck
- CXR and UA (infections can cause recrudescence of prior cva)
- ECG looking specifically for AFib
- Stat Imaging: CT Head noncontrast, followed by CTA Head/Neck and/or CT Perfusion
Treatment:
- tPA / TNK if significant neurologic deficits are present and no contraindications exist
- Thrombectomy if large vessel occlusion present without contraindications
- Admission to stroke unit to…
- Workup the etiology of stroke (usually carotid US, Echo /w bubble study, telemetry monitoring),
- Optimize treatment of risk factors such has HLD, HTN, AFib, etc
- Obtain early PT/OT/Rehab
Post-tPA Complications: Angioedema (2-5%) and Hemorrhage (2-7%)
- Have a high index of suspicion for hemorrhage – monitor for headaches, change in mental status, signs of ICP, etc
- Stop tPA immediately
- If concerned for hemorrhage, elevate head of bed and obtain STAT CT Head
- For hemorrhage, consider TXA, Platelets, Cryoprecipitate (as recommended by the AHA, however evidence is extremely poor) and consult Neurosurgery
- For Angioedema, monitor airway closely, intubate if necessary, and consider medical treatment (FFP, Antihistamines, Steroids, Epinephrine, TXA – all of which have poor evidence for benefit)
Further Reading:
MD Calc- tPA Contraindications