What is the full workup for concerns of possible stroke, and can tissue Plasminogen Activator (tPA) be administered immediately or only after receiving Computed Tomography (CT) results?

From the Guidelines

The full workup for a possible stroke involves a rapid assessment using tools like the NIHSS to evaluate neurological deficits, obtaining a detailed history including time of symptom onset, and urgent neuroimaging, with tPA administration only considered after CT results are obtained to rule out hemorrhagic stroke. A non-contrast CT scan is typically performed first, followed by CT angiography or MRI if available, as recommended by the American Heart Association/American Stroke Association guidelines 1. Laboratory tests including complete blood count, coagulation studies, electrolytes, and glucose are also essential. Regarding tPA (tissue plasminogen activator), it is administered at 0.9 mg/kg (maximum 90 mg) with 10% given as an initial bolus and the remainder infused over 60 minutes, as outlined in the guidelines 1. The treatment window is generally within 4.5 hours of symptom onset, though earlier administration yields better outcomes. Before administering tPA, blood pressure must be controlled (below 185/110 mmHg), and contraindications such as recent surgery, active bleeding, or use of anticoagulants must be ruled out, as emphasized in the guidelines 1. Key aspects of the workup and treatment include:

• Rapid neurological assessment using tools like the NIHSS
• Urgent neuroimaging with non-contrast CT scan
• Laboratory tests for complete blood count, coagulation studies, electrolytes, and glucose
• Controlled blood pressure below 185/110 mmHg before tPA administration
• Administration of tPA at 0.9 mg/kg (maximum 90 mg) with 10% as an initial bolus and the remainder infused over 60 minutes
• Monitoring for complications such as symptomatic intracranial hemorrhage, as noted in the guidelines 1.

From the Research

Full Workup for Concerns of Possible Stroke

• The full workup for concerns of possible stroke includes a comprehensive evaluation, starting with prehospital considerations and initial evaluation of the patient with history, examination, and imaging 2, 3.
• The primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction 3.

Use of tPA

• IV TPA is typically administered after obtaining CT results to confirm the absence of contraindications, such as intracranial hemorrhage 2, 3.
• However, in some cases, tPA may be administered promptly, without delay, if the patient presents with clear symptoms of acute ischemic stroke and no obvious contraindications 4.
• The use of antiplatelet agents and heparin in the 24-hour post-IV TPA window is generally discouraged, but may be necessary in certain circumstances during thrombectomy procedures 5.

Imaging and Treatment Options

• Advanced imaging techniques, such as CT or MRI, are used to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy 4.
• Treatment options, including thrombolysis and endovascular therapy, are discussed in detail in the literature, with a focus on the golden hour and the importance of rapid restoration of cerebral blood flow 2, 3.
• The specific antiplatelet regimen should be individualized based on the stroke characteristics, time from symptom onset, and patient-specific predisposition to develop hemorrhagic complications 6.