Stroke Reperfusion Therapy: IA/Catheter-based therapy

Chemical and/or mechanical therapy clot lysis or endovascular clot retrieval for eligible patients. These include patients who arrive within 3 hours but are not eligible for IV tPA, as well as those who arrive after 3 hours or who have proximal arterial occlusions and received IV tPA without benefit.

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Indications for Catheter Based (IA) Reperfusion

• A significant neurologic deficit expected to result in long-term disability.
• Deficits attributable to large vessel occlusion (basilar, vertebral, internal carotid or middle cerebral artery M1 or M2 branches).
• Non-contrast CT scan without hemorrhage or well-established infarct
• Acute ischemic stroke symptoms with onset or last known well, clearly defined. Treatment initiated within 6 to 8 hours of established, non-fluctuating deficits due to Anterior Circulation (carotid/MCA) stroke. The window of opportunity for treatment is less well defined in posterior circulation (Vertebral/ Basilar) ischemia, and patients may have fluctuating, reversible ischemic symptoms over many hours or even days and still be appropriate candidates for therapy.

Contraindications

Items marked with *** are not necessarily contraindications for mechanical thrombolysis or clot retrieval procedures. These procedures may include limited amounts of IV or IA chemical thrombolytics or antiplatelet agents.

Imaging Findings

• Intracranial hemorrhage (ICH, SAH, Subdural Hematoma, etc.)
• Well-established acute infarct on CT/MR in the territory to be reperfused ***
• Major infarction. ***
  [e.g. > 1/3 cerebral hemisphere]
• CNS lesion with high likelihood of hemorrhage s/p chemical thrombolytic agents (e.g., brain tumors, abscess, vascular malformation, aneurysm, contusion) ***
• Seizure at onset
  [if residual deficits are due to the postictal state rather than to ischemia If rapid diagnosis of vascular occlusion can be made, treatment may be given.]
• Suspicion of subarachnoid hemorrhage
  [by imaging or clinical presentation]

Warnings

Items marked with *** are not necessarily contraindications for mechanical thrombolysis or clot retrieval procedures. These procedures may include limited amounts of IV or IA chemical thrombolytics or antiplatelet agents.

These conditions may increase the risk of unfavorable outcomes but are not necessarily a contraindication to treatment:

• Recent surgery/trauma (less than 15 days) ***
• Recent intracranial or spinal surgery, head trauma, or stroke (less than 3 months) ***
• History of intracranial hemorrhage or brain aneurysm or vascular malformation or brain tumor ***
  [may consider IA catheter-based repurfusion in patients with CNS lesions that have a very low likelihood of bleeding such as small unruptured aneurysms or benign tumors with low vascularity]
• Active internal bleeding (< 22 days) ***
  [including arterial puncture at a non-compressible site]
• Platelets less than 100,000, PTT greater than 40 sec after heparin use, or PT greater than 15 or INR greater than 1.7, or known bleeding diathesis ***
• Stroke severity - too severe (e.g., NIHSS greater than 22)
  [At MGH, we typically do not exclude patients based on an increased NIHSS alone.]
• Glucose < 50 or > 400 mg/dl
  [if residual deficits are due to the altered metabolic state rather than to ischemia. If rapid diagnosis of vascular occlusion can be made, treatment may be given.]
• Left heart thrombus documented ***
• Increased risk of bleeding due to any of the following: ***
  • Acute pericarditis
  • Subacute bacterial endocarditis (SBE)
  • Hemostatic defects including those secondary to severe hepatic or renal disease
  • Pregnancy
  • Diabetic hemorrhagic retinopathy, or other hemorrhagic ophthalmic conditions
  • Septic thrombophlebitis or occluded AV cannula at seriously infected site
  • Patients currently receiving oral anticoagulants, e.g., Warfarin sodium and INR greater than 1.7
  • Advanced age
  • Status post full dose IV tPA
• Rapid improvement
  [At MGH, We typically treat patients with rapid improvement who are still with NIHSS greater than or equal to 8]
• Stroke severity too mild
  [e.g. NIHSS less than 8]
• Life expectancy less than 1 year or severe co-morbid illness or CMO on admission

Pre-Thrombolysis Management

• Start supplementary oxygen if unable to maintain O2 SAT greater than 92%. Treat any fever with rectal acetominophen. NPO for any oral intake (e.g. food, medication, etc.).
• Do not place foley, nasogastric tube, arterial line or central venous line unless it is necessary for patient safety.
• Do not place any femoral catheters (venous or arterial)
• Do not lower blood pressure unless it is causing myocardial ischemia or exceeds 220/120. Use labetolol iv (5-20 mg iv q 10-20 mins) or, if necessary, nicaripine infusion 5-15 mg/hr. Monitor with Non-invasive cuff pressures q 15 mins or continuous arterial pressure monitoring
• Do not administer Heparin unless recommended by the Acute Stroke Team
• Page Neuroradiology Emergency Beeper for STAT head CT/CTA and possible DWI.
• Page Acute Stroke Beeper and Acute Stroke Fellow if not already done
• Alert Interventional Neuroradiology and Anesthesia about possible case
• Alert NeuroICU and check for bed availability. Call Respiratory Therapy for a Ventilator to CT if intubated patient
• Consider bypassing CTA if risk is increased (e.g., renal failure, acute CHF) and it is unlikely to change treatment decision. Hold metformin 48 hrs after iodinated contrast.
• Check MRI exclusions (e.g., Severe claustrophobia, implanted pacemaker, metal fragments, shrapnel)
• Review CT/CTA with Interventionalist and Stroke Team
• Obtain written or verbal informed consent (see IA consent form) for endovascular procedure and general anesthesia from patient or appropriate caregiver. If no individual is available for consent, consider emergency consent procedures.
• If time permits, obtain STAT DWI MR imaging but do not delay time to treatment.

Peri-Thrombolysis Management

Options to consider:

• Confirm case with Anesthesia
  [Anesthesia: 6-8910]
• Discuss starting Heparin 3,000 u bolus and 800 u/hr with endovascular team
• Request OG or NG tube placement prior to thrombolytic drug infusion.
• Induced hypertension until patency restored in patients with poor collateral flow.
• Terminating infusion of thrombolytic by 8 hrs in anterior circulation stroke. Consider angioplasty or MERCI in appropriate cases.
• To prevent or treat acute re-occlusion after angioplasty or stenting, consider IV Integrilin. See Epitifbatide (Integrilin) Dosing Form
• Call respiratory therapy for ventilator delivery to Gray 2.
• Call for CT scan to be done post thrombolysis en route to Neuro ICU if portable CT not available. Repeat CT within 24 hours, consider CTA if renal and cardiovascular function permits.

Epitifbatide (Integrilin) Dosing

• View dosing form

Authoring Information

Reviewed/Approved by: Schwamm, Lee, M.D. on behalf of ASQT

Last updated: 12/23/2009