Transcript Complications following thrombolysis

Complications following
thrombolysis
Phil Sanmuganathan
Consultant Stroke Physician
Outline
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Pharmacological properties
How to avoid or minimise complications
Intracerebral haemorrhage and bleeding elsewhere
Reperfusion cerebral excitability
Cerebral oedema
Anaphylaxis and angio-oedema
Myocardial rupture
Pharmacology
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Alteplase is an enzyme
Binds to fibrin in clots
Converts plasminogen to plasmin
Plasmin initiates local fibrinolysis
Circulating fibrinogen drops by a third
Half life
distribution 5 min
excretion 40 min
How to avoid complications
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Time of onset of symptoms
Any seizure activity
Severe strokes – NIHSS >20
BP <185/110
MI, Stroke 3/12
GI, urinary bleed 3/52
Major surgery 2/52
Bleeding complications
• Symptomatic ICH 6-9% stroke compared to
0.5-0.6% MI thrombolysis
• Usually massive
• Multifocal
• 30 day mortality 60%
Intracerebral bleeding
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Destroys and displaces brain tissue
Increase ICP
Haematoma growth
Perihaematoma oedema + ischaemia
Secondary intraventricular heamorrhage
Hydrocephalus
Classification
HI 1 small petechiae infarct margins
HI 2 confluent petechiae within inf. No SOE
PH 1 clots exceeding 30% of infarct
PH2 clots exceeding 30% of infarct with SOE
PHr1 bleed away from the infarct mild SOE
PHr2 large bleed away from inf. Sig. SOE
Symptomatic ICH
Parenchymal haemorrhage type 2 on post
treatment scan
neurological deterioration with 4 point
increase in NIHSS
Parenchymal haematoma
Plac.
Rt-PA
OTT (min) n
bleed n
bleeds
0-90
150
0
161
5
91-180
315
3
302
17
181-270- 411
7
390
23
271-360
5
538
37
508
ICH Analysis
Baseline NIHSS > 20
• Age > 70 years
• Ischemic changes present on initial CT
• Glucose > 300 mg/dl (16.7 mmol/L)
# of Risk
Factors
# of patients
treated with tPA
(n=310)
# of Symptomatic
ICH’s
(# of placebo patients
with ICH)
Percentage
(%)
0
114
2 (1)
1.8
1
144
7 (1)
4.9
>1
52
11
21.2
Treatment
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Stop alteplase infusion
Airway, oxygenation, circulation
Head 300 jugular venous drainage - ICP
BP <160/90 over 6hrs
Platelet infusion 6-8 units
Cryoprecipitate 6-10 bags
Tranexemic acid 1 gm iv
FFP 15-20 ml/kg
SBP management
• SBP >200 Labetalol 50 mg iv followed by
2-8mg/min (max. 200mg)
• SBP >180 Labetalol 50mg iv
• Aim to maintain SBP around 160
CPP >60
• GTN 50mg in 50ml saline/dex. 0.6-12 ml/h
Reperfusion oedema
• Mannitol 1g/kg iv 8 hrly
• Epileptic fits
lorazepam 4mg iv
phenytoin 15mg/kg (50mg/min)
INTENSIVE CARE
ITU
• Intravenous sedation – propofol
• Hyperventilation
• Manage cardiopulmonary instability
associated with RICP
DNAR
Angio-oedema
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Common in those on ACEI
Usually self limitng
Adrenaline 1:1000 nebulised if stridor
Oxygen
Alteplase infusion can be continued if ABC
is not compromised
Anaphylaxis
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Laryngeal oedema, bronchospasm, hypotension
Stop alteplase infusion
Horizontal bed raise foot end
Airway patent
Adrenaline 1:10,000 five ml -1ml/min
Chlorpheniramine 10mg slow iv
Hydrocortisone 200 mg iv