Article

With thrombolysis, intravenous alteplase (0.9 mg/kg body weight, maximum 90 mg),
with 10% of the dose given as a bolus followed by a 60-minute infusion, is
recommended within 4.5 hours of onset of ischemic stroke. When indicated,
intravenous thrombolysis must be initiated as soon as possible. It is possible to
use intravenous alteplase in patients with seizures at stroke onset, if the
neurological deficit is related to acute cerebral ischemia. Intravenous alteplase
can be discussed for use on a case-by-case basis, according to risk of bleeding,
in selected patients under 18 years and over 80 years of age, although for the
current European recommendations this would be an off-label use. In hospitals
with a stroke unit, intravenous thrombolysis is prescribed by a neurologist
(current French labelling) or a physician having the French certification for
neurovascular diseases (outside the current French labelling). The patient must
be monitored in the stroke unit or in case of multiple organ failure in an
intensive and critical care unit. In hospitals without a stroke unit,
thrombolysis must be decided by the neurologist from the corresponding stroke
unit via telemedicine. It is recommended to perform brain imaging 24 hours after
thromboysis. Intra-arterial thrombolysis can be contemplated on a case-by-case
basis after multidisciplinary discussion within a 6-hour time window for patients
with acute middle cerebral artery or carotid occlusions, and within a larger time
window for patients with basilar artery occlusion, because of their very poor
spontaneous prognosis. Mechanical thrombectomy can also be contemplated in the
same situations. With antiplatelet agents, it is recommended that patients
receive aspirin (160 mg-325 mg) within 48 hours of ischemic stroke onset. When
thrombolysis is performed or contemplated, it is recommended to delay the
initiation of aspirin or other antithrombotic drugs for 24 hours. The use of
antiplatelet agents that inhibit the glycoprotein IIb/IIIa receptor is not
recommended. Urgent anticoagulation using heparin, low-molecular-weight heparins
or danaparoid with the goal to treat ischemic stroke patients is not recommended.
Secondary prevention by anticoagulation can be used, immediately or within the
first days, after minor ischemic stroke or TIA in patients with a high risk for
cardioembolism, if uncontrolled hypertension is absent. In patients with large
infarcts and a high risk for cardioembolism, the timing for initiating
anticoagulation must be decided on a case-by-case basis. In patients with
anticoagulation who had an ischemic stroke, the decision to temporarily stop or
maintain anticoagulation must be made on a case-by-case basis, depending on
thromboembolic risk, level of anticoagulation at stroke onset and estimated risk
of hemorrhagic transformation. It is not recommended to use neuroprotective
agents in ischemic stroke patients. Patients with cerebral venous thrombosis must
be treated with therapeutic doses of heparin, even in case of concomitant
intracranial hemorrhage related to cerebral venous thrombosis. If the patient's
status worsens despite adequate anticoagulation, thrombolysis may be used in
selected cases. The optimal administration route (local or intravenous),
thrombolytic agent (urokinase or alteplase) and dose are unknown. There is
currently no recommendation with regard to local thrombolytic therapy in patients
with dural sinus thrombosis. Urgent blood transfusions are recommended to reduce
hemoglobin S to <30% in patients with sickle cell disease and acute ischemic
stroke.
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Langue : FRANCAIS