Background & Purpose: It has been well established that intravenous alteplase (IVa) administration for treatment of acute ischemic stroke (AIS) improves clinical outcome at 3 months, and earlier treatment is more likely to result in a favorable outcome with reduced symptomatic intracranial hemorrhage (sICH). A platelet count (PC) of <100,000/mm3 remains a contraindication IVa, but the incidence is low. With the limited time to diagnose an AIS and candidacy for IVa, often lab results are received after drug initiation. Research indicates that IVa for AIS may be safe and the risk of developing sICH is low if IVa is given before PC is resulted. According to AHA/ASA guidelines, treatment is not delayed while waiting for hematologic or coagulation testing if there is no reason to suspect an abnormal test. The purpose of this study is to evaluate the incidence of asymptomatic hemorrhage (aICH), functional outcome, and safety of IVa in AIS patients with PC <100,000/mm3 prior to PC results.
Methods: We retrospectively reviewed charts of patients who received IVa from January, 2009 to July, 2017 at our facility. Patients were identified and treated based on standard FDA approved guidelines. We identified patients with admission PC <100,000/mm3. We compared admission and discharge PC and NIHSS, baseline and discharge mRS, and discharge disposition. We evaluated their medical and social history and antiplatelet use prior to admission. Brain MRI and 24 hour noncontrast CT head were reviewed.
Results: 511 patients received IVa for treatment of AIS at our facility during the study period. Four patients (0.97%) with a PC of <100,000/mm3 (70,000/mm3 – 97,000/mm3) received full dose IVa. None of the 4 subjects had a hemorrhagic complication on 24 hour CT. Upon discharge, all 4 patients had an improvement in the NIHSS (mean 3.7 points) and were functionally independent at discharge (mRS 0-1). All 4 patients were discharged home.
Conclusion: IVa treatment in AIS with PC <100,000/mm3 did not result in aICH in this group of patients. Our study supports the claim that lower PC is rare in AIS patients and there is no need to wait for PC results before starting IVa. Full dose IVa in lower PCs may be safe, but a larger sample size should be studied to further evaluate safety.