Table 10.

Inclusion and Exclusion Characteristics of Patients With Ischemic Stroke Who Could Be Treated With IV rtPA Within 3 Hours From Symptom Onset

Inclusion criteria
  Diagnosis of ischemic stroke causing measurable neurological deficit
  Onset of symptoms <3 hours before beginning treatment
  Aged ≥18 years
Exclusion criteria
  Significant head trauma or prior stroke in previous 3 months
  Symptoms suggest subarachnoid hemorrhage
  Arterial puncture at noncompressible site in previous 7 days
  History of previous intracranial hemorrhage
  Intracranial neoplasm, arteriovenous malformation, or aneurysm
  Recent intracranial or intraspinal surgery
  Elevated blood pressure (systolic >185 mmHg or diastolic >110 mmHg)
  Active internal bleeding
  Acute bleeding diathesis, including but not limited to
  Platelet count <100000/mm3
  Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the upper limit of normal
  Current use of anticoagulant with INR >1.7 or PT >15 seconds
  Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa activity assays)
  Blood glucose concentration <50 mg/dL (2.7 mmol/L)
  CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
Relative exclusion criteria
  Recent experience suggests that under some circumstances—with careful consideration and weighting of risk to benefit—patients may receive fibrinolytic therapy despite 1 or more relative contraindications. Consider risk to benefit of IV rtPA administration carefully if any of these relative contraindications are present:
  Only minor or rapidly improving stroke symptoms (clearing spontaneously)
  Seizure at onset with postictal residual neurological impairments
  Major surgery or serious trauma within previous 14 days
  Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
  Recent acute myocardial infarction (within previous 3 months)
  • The checklist includes some FDA-approved indications and contraindications for administration of IV rtPA for acute ischemic stroke. Recent guideline revisions have modified the original FDA-approved indications. A physician with expertise in acute stroke care may modify this list.

  • Onset time is defined as either the witnessed onset of symptoms or the time last known normal if symptom onset was not witnessed.

  • In patients without recent use of oral anticoagulants or heparin, treatment with IV rtPA can be initiated before availability of coagulation test results but should be discontinued if INR is >1.7 or PT is abnormally elevated by local laboratory standards.

  • In patients without history of thrombocytopenia, treatment with IV rtPA can be initiated before availability of platelet count but should be discontinued if platelet count is <100 000/mm3.

  • aPTT indicates activated partial thromboplastin time; CT, computed tomography; ECT, ecarin clotting time;FDA, Food and Drug Administration; INR, international normalized ratio; IV, intravenous; PT, partial thromboplastin time; rtPA, recombinant tissue plasminogen activator; and TT, thrombin time.