IV Tpa and previous Stroke

[NeuroDocDO]

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According to the tPA guidelines, a previous stroke within 3 months is considered an absolute contraindication. To those who administer tPA as part of their practice do you differentiate between small vs large previous stroke within past 3 months or does size not matter and the patient is excluded from tPA?

thanks

 

[typhoonegator]

Any stroke that is severe enough to cause deficits and label the patient as having had a stroke in the last 3 months is an absolute contraindication in my book. I don't try to split them as high vs. low risk (big vs. small? anterior vs. posterior?) because I just don't think we have data for that.

More difficult for me are the patients that come in and say they've been doing just fine with no recent neurologic deficits, but they have a late-subacute vs. chronic thalamic lacune on CT in addition to their new evolving event. If symptoms can't be easily attributed to that older lesion, should that really be a contraindication? It's tricky, but if it really looks well-developed and they have substantial new deficits, I treat them, but in those cases it's all based on gestalt.

 

[neglect]

I think this is a very tricky area. You are always safe to look at a contraindication to treatment and not give the IV tPA. But how strict will you be? If it was a trivial minor stroke 2.5 months ago, then I would still recommend tPA and I'd do my best to document a discussion with the family about having increased risk of a hemorrhage. I would feel very uncomfortable giving it to a patient with a recent midsized or large stroke and would not recommend it or offer it in that situation.

Luckily, this has come up only one time for me and we were right at the 3 month cut off. I gave it, no ill effects.

 

[burs0028]

I will treat most patients if their prior stroke occurred >3 weeks ago. This is not a typo. There is no evidence for the 3m cut-off that I am aware of. Like many of the "contraindications" to IV tPA use, the <3m Hx of stroke was an arbitrarily selected criteria from the initial trials that was carried forward into the FDA approval parameters. It is unlikely that after 3 weeks of healing there would still be sufficient abnormalities of vascular wall integrity, so I reason that it shouldn't raise the risk of ICH. Its a much easier decision with a prior lacune than an LVO--given they are much less likely to involve multiple larger vessels, but realistically the odds of having a pt s/p large-vessel occlusion re-present with different symptoms from a new infarct so soon after the last one are very low. Also, we re-start anti-coagulation after ICH in pts with mechanical valves on average after 10d...makes sense to me that if this is safe, why not lytics after a longer healing period?

I'm admittedly very aggressive in my approach to tPA use, but even so have yet to have a symptomatic hemorrhage after tPA (after >50 uses). As with any consideration of off-label use you have to do your best to educate the pt/family on the lack of data that apply to their particular situation. I've never regretted opting to treat a patient with tPA, but often have looked back and wished I had treated after a pt went on to worsen a "mild" stroke.

You'll never get sued for treating per the manufacturer's instructions, but I think that it is really unfortunate that so many of the so-called contraindications have no data to support them as reasons not to treat...lots of patients out there who might otherwise have a better shot at good outcomes don't get treated.

 

[neglect]

I will treat most patients if their prior stroke occurred >3 weeks ago. This is not a typo. There is no evidence for the 3m cut-off that I am aware of. Like many of the "contraindications" to IV tPA use, the <3m Hx of stroke was an arbitrarily selected criteria from the initial trials that was carried forward into the FDA approval parameters. It is unlikely that after 3 weeks of healing there would still be sufficient abnormalities of vascular wall integrity, so I reason that it shouldn't raise the risk of ICH. Its a much easier decision with a prior lacune than an LVO--given they are much less likely to involve multiple larger vessels, but realistically the odds of having a pt s/p large-vessel occlusion re-present with different symptoms from a new infarct so soon after the last one are very low. Also, we re-start anti-coagulation after ICH in pts with mechanical valves on average after 10d...makes sense to me that if this is safe, why not lytics after a longer healing period?

I'm admittedly very aggressive in my approach to tPA use, but even so have yet to have a symptomatic hemorrhage after tPA (after >50 uses). As with any consideration of off-label use you have to do your best to educate the pt/family on the lack of data that apply to their particular situation. I've never regretted opting to treat a patient with tPA, but often have looked back and wished I had treated after a pt went on to worsen a "mild" stroke.

You'll never get sued for treating per the manufacturer's instructions, but I think that it is really unfortunate that so many of the so-called contraindications have no data to support them as reasons not to treat...lots of patients out there who might otherwise have a better shot at good outcomes don't get treated.

This is fair, but you REALLY need to cover yourself. Also, what if the baseline Rankin is already 3 or 4 or even 5? A new stroke might be minimal change. A recent large MCA stroke 4 weeks ago, even with good recovery: I would not offer tPA. I have had an NIHSS of 6 with aphasia bleed all over and go ot brain death. This drug is very powerful and while I absolutely support the aggressive use of it, one cannot be caviler.

 

[burs0028]

The baseline rankin/disability is a great point and I agree has to be considered...I always ask my residents to consider what you have to gain vs. what you have to lose with tPA...no matter what, the best you can do is get them back to where they were 24hrs ago.

In my earlier reply, I was envisioning a pt with a prior LVO, but relatively minimal deficits; the prior stroke pt who's already disabled is a population we haven't studied...yet.

 

[Strokeguy]

Agree with neglect and burs0028.