Management of Acute Ischemic Stroke in Newly Diagnosed Polycythemia Vera

Immediate Assessment and Decision-Making

In a patient with newly diagnosed polycythemia vera presenting with acute ischemic stroke within the tPA window, administer intravenous thrombolysis (rtPA 0.9 mg/kg, maximum 90 mg) following standard protocols if no other contraindications exist, as the presence of PV alone does not constitute an absolute contraindication to thrombolysis, according to the American Heart Association 1, 2
Obtain non-contrast head CT immediately to exclude intracranial hemorrhage and document exact time of symptom onset, as recommended by the American College of Radiology 3, 1
Obtain CT angiography to identify large vessel occlusion, as mechanical thrombectomy remains an option regardless of PV diagnosis, according to the American Heart Association 3, 4
Verify blood pressure is controllable to <185/110 mm Hg before initiating thrombolysis, as recommended by the American Heart Association 5, 1

Administer rtPA at 0.9 mg/kg (maximum 90 mg total dose) with 10% given as IV bolus over 1 minute and remaining 90% infused over 60 minutes, according to the American Heart Association 5, 2
Initiate treatment as rapidly as possible, as earlier treatment provides greater benefit regardless of underlying hematologic condition, according to the American College of Cardiology 3, 1
Within 0-3 hours: Strong recommendation for thrombolysis (Grade 1A), according to the American Heart Association 2
Within 3-4.5 hours: Conditional recommendation for thrombolysis (Grade 2C), according to the American College of Cardiology 2

Pre-treatment: If systolic >185 mm Hg or diastolic >110 mm Hg, give labetalol 10-20 mg IV over 1-2 minutes (may repeat once) or nicardipine drip 5 mg/h titrated up by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h), as recommended by the American Heart Association 5
If blood pressure cannot be reduced below 185/110 mm Hg, do not administer rtPA, according to the American College of Cardiology 5, 1

Insert all necessary IV lines, Foley catheter, and other indwelling tubes BEFORE rtPA administration to minimize trauma and bleeding risk, as recommended by the American Heart Association 5
Monitor for orolingual angioedema (occurs in 1.3-5.1% of rtPA patients), which is more common with ACE inhibitor use, according to the American College of Cardiology 1
If angioedema develops, administer IV ranitidine, diphenhydramine, and methylprednisolone, as recommended by the American Heart Association 1

If CT angiography demonstrates large vessel occlusion, proceed directly to mechanical thrombectomy consultation, according to the American Heart Association 3, 4
Mechanical thrombectomy can be performed up to 6 hours (or longer with advanced imaging selection) and is not contraindicated by PV, according to the American College of Cardiology 3
Do not delay rtPA administration to obtain vascular imaging if patient meets clinical criteria for thrombolysis, as recommended by the American Heart Association 3

Perform neurological assessments every 15 minutes during rtPA infusion and for 2 hours after, then every 30 minutes for 6 hours, then hourly for 16 hours, as recommended by the American Heart Association 5
Obtain urgent head CT if patient develops acute neurological deterioration, severe headache, acute hypertension, nausea, or vomiting, according to the American College of Cardiology 1
The risk of symptomatic ICH is 1.6% in registry data but 6.4% in clinical trials, and may be higher with extreme thrombocytosis, according to the American Heart Association 1, 2