What are the guidelines for antiplatelet and fibrinolytic (thrombolytic) therapy in a 62-year-old man presenting with sudden onset of aphasia (difficulty speaking) and left-sided weakness, who meets initial criteria for fibrinolytic therapy and is undergoing a computed tomography (CT) scan of the brain?

From the Guidelines

For a 62-year-old man with sudden speech difficulty and left-sided weakness who meets criteria for fibrinolytic therapy, immediate administration of IV recombinant tissue plasminogen activator (rtPA/alteplase) is recommended at a dose of 0.9 mg/kg (maximum 90 mg), with 10% given as an initial bolus and the remainder infused over 60 minutes, as per the guidelines from the American Heart Association/American Stroke Association 1. This should be administered within 4.5 hours of symptom onset after confirming no hemorrhage on CT scan. Prior to fibrinolytic therapy, check blood pressure (maintain <185/110 mmHg), obtain baseline labs including coagulation studies, and assess for contraindications. For antiplatelet therapy,

• aspirin 325 mg should be initiated within 24-48 hours after fibrinolytic therapy (not before, due to bleeding risk) 1,
• or if the patient is not eligible for fibrinolytics, aspirin 325 mg should be given immediately. Following the acute phase,
• dual antiplatelet therapy with aspirin 81 mg daily plus clopidogrel 75 mg daily for 21 days may be beneficial,
• followed by single antiplatelet therapy long-term, as supported by the most recent guidelines from the World Stroke Organization 1 and the Canadian Stroke Best Practice Recommendations 1. Fibrinolytic therapy works by converting plasminogen to plasmin, which breaks down the clot obstructing cerebral blood flow, while antiplatelet agents prevent further clot formation and reduce the risk of recurrent stroke. Key considerations include:
• The importance of prompt administration of fibrinolytic therapy within the recommended time window,
• The need for careful patient selection and monitoring for potential complications,
• The role of antiplatelet therapy in secondary prevention of stroke, as emphasized in the guidelines from the American Heart Association/American Stroke Association 1, and
• The consideration of dual antiplatelet therapy in specific patient populations, such as those with high-risk transient ischemic attack or minor stroke, as recommended by the World Stroke Organization 1 and the Canadian Stroke Best Practice Recommendations 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Guidelines for Anti-Platelet and Fibrinolytic Therapy

The patient in question, a 62-year-old man experiencing difficulty speaking and left-sided weakness, meets the initial criteria for fibrinolytic therapy. According to the studies, here are the guidelines for anti-platelet and fibrinolytic therapy:

• Fibrinolytics, such as alteplase (tPA), tenecteplase (TNK), and reteplase (rPA), are used to lyse blood clots and improve vascular flow 2.
• Patients with acute ischemic stroke (AIS) who present within 3-4.5 hours of measurable neurologic deficit with no evidence of intracerebral hemorrhage (ICH) or other contraindications may be eligible to receive tPA or TNK 2.
• Antiplatelet medications should be administered in patients with acute myocardial infarction (AMI) receiving fibrinolytics, unlike in AIS and pulmonary embolism (PE) 2.
• Fibrinolytics are recommended in patients with high-risk PE (hemodynamic instability), as they reduce the risk of mortality 2.

Mechanical Thrombectomy and Fibrinolytic Therapy

The use of mechanical thrombectomy (MT) with or without intravenous tissue plasminogen activator (IV-tPA) for AIS is also discussed in the studies:

• Administering tPA prior to MT may improve the rates of recanalization compared to MT alone in tPA-eligible patients being treated for AIS, but a corresponding improvement in functional and safety outcomes was not present in one review 3.
• The use of intra-arterial adjunctive medications (IAMs) during MT may achieve better functional outcomes and lower mortality rates in patients with AIS and large vessel occlusion 4.
• A systematic review of outcome after ischemic stroke due to anterior circulation occlusion treated with intravenous, intra-arterial, or combined intravenous+intra-arterial thrombolysis found no evidence that one reperfusion strategy is superior with respect to efficacy or safety 5.

Intra-Arterial Thrombolysis

Intra-arterial thrombolysis can be administered within 6 hours of symptom onset in anterior circulation strokes and within 24 hours in posterior circulation strokes 6.

• The indications, patient selection, and technique for intra-arterial administration of thrombolytics are described in one review 6.