The bottom line in stroke therapy is to find a way to open up an occluded artery as quickly as possible. However, it must be kept in mind that there is a risk involved – in around 6% of patients, a potentially fatal hemorrhagically transformed ischaemic stroke can occur.
Another important point is that neither age, sex, stroke severity or the availability of collateral blood supply predicts non-responding for thrombolysis. “The only factor known to affect non-responding for thrombolysis is time,” Dr Terblanche said.
“Time is everything in stroke management, so we cannot wait to know if there is a bleeding tendency in a patient before beginning treatment,” Dr Terblanche said. However, three simple questions must be asked as soon as possible before commencing treatment. These are:
- Is the patient taking an oral anticoagulant?
- Is the patient taking heparin or low molecular weight heparin?
- Is the patient on hemodialysis?
Thrombolysis is also not contra-indicated in patients with rapidly improving stroke symptoms, if those symptoms are considered non-disabling. “This again proves that we should be thinking of reasons to thrombolyse, not of reasons not to thrombolyse,” Dr Terblanche said.
Consent is also not strictly necessary anymore for thrombolysis for the treatment of ischaemic stroke, since it is deemed an approved therapy. Nonetheless, it often helps to gain some form of consent from the patient or his/her family.
“The best consent form I can think of is an angiogram,” Dr Terblanche said. “I can show the patient’s family what a middle cerebral artery should look like, versus what the patient’s looks like. In these cases, a picture speaks a thousand words.”
This also serves to put the patient and their family at ease, since it becomes obvious that thrombolysis to open an occluded artery is the right way to go.
According to American Heart Association guidelines, thrombolysis can be considered I pregnancy when the anticipated benefits of treating moderate to severe stroke outweigh the risks of uterine bleeding. “Actilyse does not cross the placenta, and mechanical thrombectomy can also be attempted in pregnancy,” Dr Terblanche said.
Observational data has found that the use of acute reperfusion therapy in pregnant and postpartum women was associated with similar outcomes as non-pregnant women.