Use of Actilyse in acute ischaemic stroke

What are the service implications of using Actilyse® in clinical practice?

Following a stroke, "time is brain" and patients need to be admitted as an acute medical emergency if they are to benefit from treatment with Actilyse®.

Given the strict therapeutic time window for the use of Actilyse® and the necessary process of patient selection, the following key practices are included in the recommendations of TARGET: Stroke, based on "Get with the guidelines: Stroke patient management":

  • Advance notification of the emergency medical services.
  • Rapid triage and notification of the stroke unit and one-call mobilisation of the acute stroke care team prior to the arrival of the patient.
  • An acute care setting staffed by physicians experienced in the diagnosis and management of acute stroke including the administration of Actilyse®, which can be pre-mixed and prepared before the patient’s arrival.
  • Rapid, priority access to imaging facilities (computed tomography or magnetic resonance imaging) together with personnel experienced in the detection of intracranial haemorrhage, early signs of significant infarction and other intracranial pathology.
  • Centres should have a written protocol specifying requirements for treating and monitoring Actilyse® patients and procedures for emergency situations.
  • Results of continuous monitoring of response times, door-to-needle times, and Actilyse® administration rates should be feedback to the stroke team to ensure that they meet their goals.

(AHA/ASA 2010: TARGET: STROKE Resource Manual. Time lost is brain lost.)

How to use Actilyse®

  • Give as soon as possible after symptom onset and within 4.5* hours of stroke symptom onset
  • Total dose 0.9 mg/kg (maximum 90 mg):
    • 10% by i.v. bolus, remainder by i.v. infusion over 60 minutes
  • Avoid aspirin or i.v. heparin in the 24 hours after treatment with Actilyse®

*In some countries, Actilyse® is only licensed for use within the first 3 hours of stroke symptom onset. Please check your local licensing regulations for Actilyse®.

 

Dosage

Contra-indications

CT imaging

Other imaging

AHA/ASA*

  • I.V. rt-PA (0.9 mg/kg, maximum 90 mg)
  • 10% given as a bolus
  • Then infusion over 60 minutes within 3 hours of onset of ischaemic stroke wherever possible, and up to 4.5 hours in eligible patients

I.V. administration of streptokinase is not recommended for management of ischaemic stroke

Brain imaging (either CT or MRI) should be interpreted by an experienced clinician before starting thrombolytic therapy

Additional information in the diagnosis of ischaemic stroke may be provided by multimodal CT or MRI

ESO#

  • I.V. rt-PA (0.9 mg/kg body weight, maximum 90 mg)
  • 10% given as a bolus
  • Then infusion over 60 minutes is recommended within 4.5 hours of onset of ischaemic stroke
 

In patients with a suspected stroke or TIA, urgent brain imaging (CT or MRI) should be obtained to guide routine thrombolysis treatment with rt-PA

The use of multimodal imaging may be useful for patient selection for thrombolysis but is not recommended for routine clinical practice

 

* AHA/ASA (The American Heart Association) Del Zoppo et al. Stroke 2009;40:2945-2948.

# ESO (The European Stroke Organisation) www.eso-stroke.org

Current guidelines for acute stroke management, such as the European Stroke Organisation (ESO) recommendations and the American Stroke Association guidelines recommend the use of intravenous rt-PA within 4.5 hours of onset of ischaemic stroke as Level 1 and Class A recommendation.

Actilyse® reconstitution