Can streptokinase be given prophylactically for stroke without knowing if it's ischemic or hemorrhagic?

Streptokinase Should NEVER Be Given Prophylactically or Empirically in Stroke Without Knowing the Type

Streptokinase is absolutely contraindicated in acute stroke management and should never be administered without first confirming the stroke is ischemic (not hemorrhagic) through neuroimaging. 1

Critical Evidence Against Streptokinase Use

Streptokinase is Not Approved for Stroke Treatment

• The American Heart Association explicitly states that IV streptokinase cannot be safely substituted for rtPA in stroke treatment. 1
• Streptokinase administration is not recommended outside clinical trial settings for stroke, with a Class III (No Benefit) recommendation. 1, 2
• Multiple large randomized trials of streptokinase in acute ischemic stroke were terminated prematurely due to excess deaths and hemorrhagic complications. 3

Catastrophic Outcomes with Streptokinase

• Combined trial data show streptokinase caused an absolute mortality excess of 11.7% compared to placebo in stroke patients. 3
• Streptokinase increased cerebral hemorrhage by an absolute 10.7% compared to placebo. 3
• When combined with aspirin, streptokinase doubled early case fatality (OR 2.1) and doubled hemorrhagic transformation risk (OR 2.2). 4
• The Australian Streptokinase Trial found excess deaths in patients treated after 3 hours (RR 1.98), with 13.2% developing hematomas (12.6% symptomatic). 5

Why Imaging Must Come First

Hemorrhagic Stroke is an Absolute Contraindication

• Active intracranial hemorrhage or primary hemorrhagic stroke is an absolute contraindication to any thrombolytic therapy, including prophylactic anticoagulation. 6
• Administering thrombolytics to a hemorrhagic stroke patient would be catastrophic, causing massive expansion of bleeding and near-certain death. 6
• Approximately 15-20% of strokes presenting clinically as "stroke" are hemorrhagic, making empiric thrombolysis extremely dangerous. 1

CT Scan is Mandatory Before Any Thrombolytic

• Urgent CT imaging is required primarily to determine that ischemic stroke (not hemorrhage) is the cause before considering any thrombolytic therapy. 1
• Even for approved thrombolytics like rtPA, neuroimaging must exclude hemorrhage before administration. 1

The Only Approved Thrombolytic for Stroke

rtPA (Alteplase) is the Standard

• If thrombolysis is indicated after confirming ischemic stroke on imaging, only IV rtPA (0.9 mg/kg, maximum 90 mg) within 3 hours is strongly recommended. 1
• rtPA showed functional recovery benefit in 7.6% of patients with an absolute mortality excess of only 1.1%, far superior to streptokinase's 11.7% mortality excess. 3
• Tenecteplase (0.4 mg/kg) may be considered as an alternative to alteplase in select patients, but streptokinase remains contraindicated. 1

Prophylactic Anticoagulation Considerations

VTE Prophylaxis Only After Confirming Stroke Type

• For ischemic stroke patients with restricted mobility, prophylactic-dose subcutaneous LMWH or UFH can be given for VTE prevention, but only after hemorrhage is excluded. 6
• For primary intracerebral hemorrhage, prophylactic anticoagulation should be delayed until days 2-4 and only if follow-up imaging shows no hemorrhage expansion. 6
• Intermittent pneumatic compression devices are the safest alternative and should be applied within 24 hours when stroke type is uncertain. 6

Critical Pitfalls to Avoid

• Never assume a stroke is ischemic based on clinical presentation alone - approximately 15-20% are hemorrhagic and clinically indistinguishable. 1
• Never use streptokinase for stroke under any circumstances - it has been proven harmful with excess mortality and hemorrhage. 3, 5
• Never give prophylactic anticoagulation before neuroimaging - if the stroke is hemorrhagic, this could be fatal. 6
• Streptokinase is highly antigenic, causes prolonged anticoagulant effects, and induces hypotension that may worsen stroke outcomes. 2, 3