Treatment
Table 8. 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 BP (systolic >185 mm Hg or diastolic >110 mm Hg)
Active internal bleeding
Acute bleeding diathesis, including but not limited to:
• Platelet count <100,000/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 one
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)
• Pregnancy
• 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 FDAapproved 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.
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