When to administer Streptokinase for acute ischemic stroke or pulmonary embolism?

Streptokinase Administration Guidelines for Acute Ischemic Stroke and Pulmonary Embolism

Streptokinase is NOT recommended for acute ischemic stroke due to increased mortality and hemorrhagic complications, while it may be considered for massive pulmonary embolism with hemodynamic instability when other thrombolytics are unavailable. 1

Acute Ischemic Stroke

Contraindication for Ischemic Stroke

• Clinical trials of streptokinase for acute ischemic stroke were halted prematurely due to excess mortality and poor outcomes 1
• The Multicenter Acute Stroke Trial-Europe (MAST-E) demonstrated significantly higher 10-day mortality with streptokinase (34.0% vs 18.2% with placebo) 2
• Hemorrhagic transformation of ischemic cerebral infarcts was the main cause of increased mortality with streptokinase 1, 2
• The dose of streptokinase used in stroke trials (1.5 million units) may have been too high for stroke patients 1

Recommended Alternative for Ischemic Stroke

• Intravenous rtPA (alteplase) at 0.9 mg/kg (maximum 90 mg) is the only FDA-approved thrombolytic for acute ischemic stroke 1, 3
• rtPA should be administered within 3 hours of symptom onset (Level A recommendation) 1
• rtPA may be considered between 3-4.5 hours after symptom onset in selected patients (Level B recommendation) 1
• Patient selection for rtPA requires careful adherence to inclusion/exclusion criteria to minimize bleeding risk 1

Pulmonary Embolism

Indications for Streptokinase in Pulmonary Embolism

• Consider streptokinase for patients with massive pulmonary embolism defined as: 1, 4
  • Acute pulmonary emboli obstructing blood flow to a lobe or multiple lung segments 1
  • Acute pulmonary emboli with unstable hemodynamics (shock or hypotension) 1
• Meta-analyses suggest thrombolysis may reduce death or PE recurrence in high-risk PE patients 1

Dosing for Pulmonary Embolism

• The recommended dose is 1.5 million units administered intravenously over 1 hour 5
• Early administration (within 6 hours of symptom onset) is associated with better outcomes 5
• Risk factors for poor outcomes include right ventricular global hypokinesis, severe pulmonary arterial hypertension, and hypoxemia 5

Monitoring During Treatment

• Close monitoring of vital signs, particularly blood pressure, is essential during infusion 5
• Watch for bleeding complications, which are the most common adverse events 6
• Parenteral anticoagulation should be initiated after thrombolysis when coagulation parameters normalize 1

Contraindications and Precautions

Absolute Contraindications

• Recent intracranial hemorrhage 1
• Known structural cerebral vascular lesion 1
• Known malignant intracranial neoplasm 1
• Ischemic stroke within 3 months 1
• Suspected aortic dissection 1
• Active bleeding or bleeding diathesis 1

Relative Contraindications

• Severe uncontrolled hypertension (systolic >185 mm Hg or diastolic >110 mm Hg) 1
• Recent major surgery or trauma 1
• Recent gastrointestinal or urinary tract hemorrhage (within 21 days) 1
• Recent arterial puncture at noncompressible site 1

Complications Management

Bleeding Complications

• Minor bleeding occurs in approximately 3.6% of patients 6
• Major hemorrhage requiring transfusion occurs in about 0.4% of patients 6
• If significant bleeding occurs, discontinue the infusion immediately 1
• For cerebral hemorrhage, immediate neurosurgical consultation is required 1

Hypotension

• Symptomatic hypotension may occur during streptokinase infusion 7
• Monitor blood pressure frequently during administration 5
• If hypotension occurs, temporarily reduce or stop the infusion and provide supportive care 5

Key Pitfalls to Avoid

• Never use streptokinase for acute ischemic stroke due to increased mortality risk 1, 2
• Do not delay treatment in massive pulmonary embolism with hemodynamic instability 1, 5
• Avoid using streptokinase in patients with previous exposure due to potential allergic reactions 1
• Do not administer streptokinase boluses as this increases bleeding risk 8
• Do not use anticoagulants or antiplatelet agents within 24 hours after thrombolytic therapy for stroke 1