A 62-year-old man suddenly experienced difficulty speaking and left-sided weakness. He meets initial criteria for fibrinolytic therapy, and a CT scan of the brain is ordered. Which best describes the guidelines for antiplatelet and fibrinolytic therapy
The Correct Answer and Explanation is:
Correct Answer:
If the CT scan shows no evidence of intracranial hemorrhage, fibrinolytic therapy (such as intravenous alteplase) can be administered within the recommended time window. Antiplatelet agents like aspirin should not be given within the first 24 hours after administering fibrinolytic therapy to reduce the risk of bleeding complications. If fibrinolytic therapy is not given, aspirin should be started within 24 to 48 hours of symptom onset.
Explanation:
In the setting of an acute ischemic stroke, prompt evaluation is critical to determine eligibility for fibrinolytic therapy, also known as thrombolytic therapy. The most commonly used agent is alteplase (recombinant tissue plasminogen activator or rt-PA), which works by dissolving the clot obstructing blood flow to the brain.
Before fibrinolytic therapy is initiated, a non-contrast CT scan of the brain is required to exclude intracranial hemorrhage. If the CT scan shows bleeding, fibrinolytic therapy is contraindicated. However, if no bleeding is seen and the patient meets all inclusion criteria, fibrinolytic therapy can be administered. The current guidelines recommend administering alteplase within 4.5 hours of symptom onset, though the sooner it is given, the better the outcomes.
Antiplatelet therapy, particularly aspirin, plays a key role in secondary stroke prevention by reducing the risk of recurrent ischemic events. However, when fibrinolytic therapy is used, aspirin or other antiplatelet agents should be delayed for at least 24 hours after administration of alteplase to minimize the risk of intracranial or systemic bleeding.
If fibrinolytic therapy is not administered due to contraindications or exceeding the time window, aspirin should be started within 24 to 48 hours of stroke onset to reduce the risk of further ischemic injury.
In summary, the decision regarding antiplatelet and fibrinolytic therapy is guided by brain imaging results and the timing of symptom onset, with the priority being patient safety and maximizing neurological recovery.
