|Diagnosis of ischemic stroke causing measurable neurological deficit|
|Onset of symptoms <3 hours before beginning treatment|
|Aged ≥18 years|
|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.