Is a patient experiencing a possible stroke with an intravenous line (IV) placed?

From the Guidelines

For a patient experiencing a possible stroke with an IV placed, immediate administration of tissue plasminogen activator (tPA) should be considered if the patient arrives within 3 hours of symptom onset and has no contraindications, as recommended by the American College of Emergency Physicians clinical policy 1. The standard dose is 0.9 mg/kg (maximum 90 mg) with 10% given as an initial bolus and the remainder infused over 60 minutes. Before tPA administration, several critical steps must be taken:

• Obtain a non-contrast CT scan to rule out hemorrhagic stroke, as this is a crucial contraindication for tPA administration 1.
• Check blood glucose, as hypoglycemia can mimic stroke symptoms.
• Assess vital signs, including blood pressure, which should be maintained below 185/110 mmHg (using labetalol 10-20 mg IV or nicardipine 5 mg/hr IV if needed). Other immediate interventions include:
• Supplemental oxygen if saturation is below 94%.
• Cardiac monitoring. Perform the NIH Stroke Scale assessment to document baseline neurological status. For patients outside the tPA window or with contraindications, consider mechanical thrombectomy if a large vessel occlusion is present. These interventions are critical as time is brain tissue—approximately 1.9 million neurons die each minute during an ischemic stroke, making rapid assessment and treatment essential for preserving brain function and improving outcomes, as highlighted in the context of stroke management 1.

From the FDA Drug Label

Because of the risk of damage to the vascular wall or collapse of soft‑walled catheters, vigorous suction should not be applied during attempts to determine catheter occlusion. The most frequent adverse reaction associated with all thrombolytics in all approved indications is bleeding Death and permanent disability have been reported in patients who have experienced stroke and other serious bleeding episodes when receiving pharmacologic doses of a thrombolytic.

The patient is experiencing a possible stroke and has an IV placed. tPA (IV) can be administered in this scenario, but caution should be exercised due to the risk of bleeding, particularly in critical locations such as intracranial, gastrointestinal, retroperitoneal, or pericardial.

• Key considerations:
  • Risk of bleeding
  • Risk of damage to the vascular wall
  • Monitoring for signs of hypersensitivity 2, 2

From the Research

Patient Experiencing Possible Stroke with IV Placed

• The patient is likely to receive intravenous recombinant tissue plasminogen activator (rtPA) as the standard of care for acute ischemic stroke, as stated in the study published in Mayo Clinic proceedings 3.
• Time from stroke symptom onset to thrombolysis is crucial and probably the most important determinant of success of IV therapy, highlighting the need for prompt treatment 3.
• The use of antiplatelet therapy, such as aspirin, clopidogrel, and dipyridamole, is essential for secondary prevention of stroke recurrence and complications, as discussed in the Romanian journal of morphology and embryology 4.
• Dual antiplatelet therapy (DAPT) may be considered for short-term use in patients with high-risk transient ischemic attack or mild-moderate ischemic stroke, as it reduces the risk of recurrent stroke, but increases the risk of major bleeding events, according to the study published in Stroke 5.

Treatment Decision-Making

• Intravenous alteplase treatment can influence physicians' decision-making for endovascular treatment (EVT) in primary medium-vessel occlusion stroke, with a lower chance of a decision in favor of immediate EVT, as found in the Journal of neurointerventional surgery 6.
• Antiplatelet therapy as an adjunct to EVT may be associated with a higher likelihood of successful recanalisation and 3-month functional independence, but the results are unstable and require further confirmation, as stated in the Journal of clinical neuroscience 7.

Key Considerations

• The importance of prompt treatment and community education in optimizing care for patients with acute stroke 3.
• The need for standardized protocols to guide immediate patient assessment and triage to medical centers with capability for efficient neurologic assessment, brain imaging, drug administration, and specialized postthrombolysis care 3.
• The role of antiplatelet therapy in secondary prevention of stroke recurrence and complications, and the potential benefits and risks of DAPT in specific patient populations 4, 5.