eMedicine Specialties > Neurology > Neuro-vascular Diseases

Thrombolytic Therapy in Stroke: Follow-up

Author: Jeffrey L Saver, MD, Director, Stroke Center, Professor, Department of Neurology, University of California at Los Angeles Medical Center
Coauthor(s): Mary Kalafut, MD, Director, Stroke Center, Scripps Clinic, Green Hospital
Contributor Information and Disclosures

Updated: Aug 11, 2009

Follow-up

Further Inpatient Care

  • After thrombolytic therapy is initiated, transfer the patient to an intensive care unit, stroke unit, or other unit capable of close observation.
  • No antiplatelet or anticoagulant therapy should be administered for 24 hours following tPA.
  • Obtain a repeat head CT scan or MRI 24 hours after tPA to rule out asymptomatic hemorrhagic transformation prior to initiating antithrombotic therapy.
  • BP should be monitored closely and controlled.
  • Physical, occupational, and speech therapy can be initiated after the first 24 hours of bedrest.

Transfer

Transfer should be initiated if CT or MRI is not available. However, remember that the time to transfer a patient may exceed the 3-hour time-window for treatment.

Complications

  • Intracerebral hemorrhage
    • In the NINDS trials, the rate of combined minor and major symptomatic ICH (ie, any clinical worsening temporally coincident with any new ICH) 24-36 hours after treatment was 6.4% with tPA versus 0.6% without tPA.
    • ICH may be signaled by acute hypertension, headache, neurological deterioration, and nausea or vomiting.
    • If ICH is suspected, obtain an emergent head CT scan and obtain PT, aPTT, platelet count, and fibrinogen.
    • If ICH is present on CT scan, evaluate lab studies and administer, if needed, 6-8 units of cryoprecipitate containing fibrinogen and factor VIII, 6-8 units of platelets, and/or fresh frozen plasma. Use of recombinant factor VII may also be considered but carries a risk of inducing thrombotic events.
    • Obtain neurosurgery consultation.
    • Obtain hematology consultation.
  • Oozing from intravenous line and venous puncture sites (up to 30% of cases)
  • Angioedema (rare)

Prognosis

  • Neurologic deficits: Three months following tPA therapy, approximately 30% of patients are neurologically normal or near normal; 30% have mild to moderate neurological deficits; 20% have moderate to severe neurological deficits; and 20% have died.
  • Functional disability: Three months following tPA therapy, approximately 50% of patients are completely or almost completely independent in activities of daily living; 15% are moderately dependent on others; 15% are completely dependent on others; and 20% have died.

Patient Education

  • Education regarding the availability of thrombolytic therapy for stroke is important for patients with risk factors for stroke and those who have experienced a transient ischemic attack or prior stroke.
  • Emphasizing the importance of arriving at the hospital as early as possible for treatment is imperative.
  • The 4 main warning signs of an acute ischemic stroke are the following:
    • Sudden weakness or numbness on one side of the body
    • Sudden loss or change of vision
    • Sudden speech difficulty or language comprehension difficulty
    • Sudden dizziness or gait difficulty
  • Patients should be instructed that if they experience any of these symptoms and the symptoms last for 5 minutes, they should call 911 immediately or be driven to the nearest emergency department (American Heart Association guidelines).
  • For excellent patient education resources, visit eMedicine's Stroke Center. Also, see eMedicine's patient education article Stroke.

Miscellaneous

Medicolegal Pitfalls

  • Identifying the onset time as the time when the symptoms were first observed rather than the last time the patient was known to be well
  • Not following the FDA-approved inclusion/exclusion criteria for thrombolytic therapy with tPA in stroke
  • Failing to discuss with the patient and family the benefits and risks of thrombolytic therapy, including potential for ICH, worsening of neurological deficits, coma, and death
  • Failing to proceed with thrombolytic therapy when it is consistent with best clinical practice and judgment because the patient is unable to authorize treatment and a legally authorized representative is not available
  • Administering anticoagulants or antiplatelet agents during first 24 hours after intravenous tPA
  • Failing to notify the local EMS system of the hospital's readiness to provide thrombolytic therapy, and continuing to accept direct ambulance routing of stroke patients when the facility is not treatment-capable.
  • Failing to offer or administer tPA therapy to patients who are candidates probably the most common cause of tPA-related malpractice litigation.27
 


More on Thrombolytic Therapy in Stroke

Overview: Thrombolytic Therapy in Stroke
Differential Diagnoses & Workup: Thrombolytic Therapy in Stroke
Treatment & Medication: Thrombolytic Therapy in Stroke
Follow-up: Thrombolytic Therapy in Stroke
Multimedia: Thrombolytic Therapy in Stroke
References
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References

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Further Reading

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Keywords

stroke therapy, stroke treatment, stroke symptoms, thrombolytic therapy, acute stroke, acute stroke therapy, acute cerebral ischemia, fibrinolysis, fibrinolytic, tissue plasminogen activator, tPA, t-PA, clot buster, stroke, thrombosis, hemorrhage, embolism, cerebral accident

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Contributor Information and Disclosures

Author

Jeffrey L Saver, MD, Director, Stroke Center, Professor, Department of Neurology, University of California at Los Angeles Medical Center
Jeffrey L Saver, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Neurological Association, and National Stroke Association
Disclosure: Boehringer-Ingelheim - Secondary Prevention Consulting fee Consulting; Talacris Consulting fee Consulting; ImaRx Consulting fee Consulting

Coauthor(s)

Mary Kalafut, MD, Director, Stroke Center, Scripps Clinic, Green Hospital
Mary Kalafut, MD is a member of the following medical societies: American Academy of Neurology and American Heart Association
Disclosure: Nothing to disclose.

Medical Editor

Richard M Zweifler, MD, Chief of Neurology, Sentara Healthcare, Norfolk, VA; Professor of Neurology, Eastern Virginia Medical School, Norfolk, VA
Richard M Zweifler, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Stroke Association, Royal Society of Medicine, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health & Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

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