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DIAGNOSIS

■ Clinical diagnosis, based on complete resolution of findings within 24 hours

■ Evaluation for underlying etiology includes: ECG, carotid USN, cardiac

echocardiogram (in selected patients).

TREATMENT

■ Antiplatelet agent (aspirin, clopidogrel or ticlopidine) is primary therapy.

■ Goal is prevention of stroke, based on suspected underlying process (eg,

anticoagulation if mural thrombus).

NEUROLOGY

Consider intra-arterial

thrombolysis in patients with

brainstem strokes (even in

delayed presentations).

TABLE 15.2. Criteria for Intravenous Thrombolysis in Ischemic Stroke

INCLUSION EXCLUSION*

Age 18 years or older Minor stroke symptoms

Clinical diagnosis of ischemic stroke Rapidly improving neurologic signs

Time since onset well established Prior intracranial hemorrhage

to be less than 3 hr

Blood glucose <50 mg/dL or >400 mg/dL

Seizure at onset of stroke

GI or GU bleeding within preceding 21 days

Recent myocardial infarction

Major surgery within preceding 14 days

Sustained pretreatment

SBP >185 mmHg or

DBP >110 mmHg

Previous stroke within preceding 90 days

Previous head injury within preceding 90 days

Current use of oral anticoagulants or PT >15 s or INR >1.7

Use of heparin within preceding 48 hr and a prolonged PTT

Platelet count <100,000/μL

∗Caution is advised before giving tPA to persons with severe stroke (NIH Stroke Scale Score

greater than 22).

Abbreviations:DBP = diastolic blood pressure; GI = gastrointestinal; GU = genitourinary; INR =

international normalized ratio; PT = prothombin time; PTT = partial prothrombin time; SBP =

systolic blood pressure.

(Reproduced, with permission, from Tintinalli JE, Kelen GD, Stapczynski JS. Emergency Medicine:

A Comprehensive Study Guide,6th ed. New York: McGraw-Hill, 2004:1386 based on data from

Adams HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: A

supplement to the guidelines for the management of patients with acute ischemic stroke.

Circulation94:1167, 1996.)