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Stroke Survivors

Eligibility for acute ischemic stroke

Thrombolytic treatment eligibility for acute ischemic stroke

Provides inclusion/exclusion criteria when deciding to use tPA on a patient with acute ischemic stroke.

Disclaimer: This is meant to be a quick reference and should not be used solely for medical decision making. Practice should be guided by institutional protocols and consultation with Neurologist.

Eligibility for tPA

  • Age ≥18
  • Clinical diagnosis of ischemic stroke causing neurological deficit
  • Time of symptom onset <4.5 hours (See 3-4.5hr warnings below)

Absolute Contraindications to tPA

  • Intracranial hemorrhage on CT
  • Clinical presentation suggests subarachnoid hemorrhage
  • Neurologic surgery, serious head trauma, or previous stroke in past 3 months
  • History of intracranial hemorrhage
  • Known arteriovenous malformation, neoplasm, or aneurysm
  • Active internal bleeding
  • Suspected/confirmed endocarditis
  • Known bleeding diathesis, including:
    • Platelet count < 100,000
    • Patient has received heparin within 48 hours and has an elevated aPTT (greater than upper limit of normal for laboratory)
    • Current use of oral anticoagulants (ex: warfarin) and INR >1.7
    • Current use of direct thrombin inhibitors or direct factor Xa inhibitors
  • Pregnancy

Relative Contraindications/Warnings to tPA

  • Only minor or rapidly improving stroke symptoms
  • Patient has had major surgery or serious trauma excluding head trauma in the previous 14 days
  • History of gastrointestinal or urinary tract hemorrhage within 21 days
  • Recent arterial puncture at a noncompressible site
  • Recent lumbar puncture
  • Post myocardial infarction pericarditis
  • Seizure at stroke onset
  • Abnormal blood glucose ( <50 or >400 mg/dL)
  • Uncontrolled hypertension (>185 mmHg SBP or >110 mmHg DBP)

Additional Warnings to tPA >3hr Onset

  • Age >80 years
  • History of prior stroke and diabetes
  • Any active anticoagulant use (even with INR <1.7)
  • NIHSS > 25
  • CT shows multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Nattasha Acevedo, MD

Dr. Acevedo received her medical degree from the Ponce School of Medicine in Puerto Rico and did her neurology residency at Montefiore Medical Center in New York. She went on to do a clinical neurophysiology fellowship at Emory School of Medicine in Atla nta, Georgia and then joined private practice in Fort Myers, Florida. She currently resides in San Juan, Puerto Rico. She likes running, paddle boarding and spending time with family.
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Bernadette Borte, MD

Dr. Borte received her medical degree from St. Matthew’s University School of Medicine in Grand Cayman. She completed her neurology residency at the University of Iowa Hospitals and Clinics in Iowa City, Iowa. Her areas of interest include inpatient neurology and acute stroke. When not working, she enjoys spending time outdoors with her family. Dr. Borte joined the TeleSpecialist family in March of 2019.
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Mazen Almidani, MD

Dr. Almidani is board certified in pediatrics by the American Board of Pediatrics and board certified in epilepsy, as well as neurology with special  qualification in child neurology by the American Board of Psychiatry and Neurology.  Dr. Almidani is happily married with 4 children. His oldest son has autism and his daughter has complicated seizures; both were a drive for him to become a neurologist. Dr. Almidani enjoys soccer, running and spending time with his family. He is very involved with his sons’ therapy and helping with daily challenges. He is double board certified in Pediatric and Adult Neurology and Epilepsy. He sees children and adults. He also participates in charities for children in Syria who may be underprivileged and/or affected by the war. Dr. Almidani joined TeleSpecialists in August 2020.
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Amanda Cheshire, MD

Dr. Cheshire received her medical degree from the University of Louisville School of Medicine in Louisville, Kentucky. She completed her neurology residency at the University of Cincinnati Medical Center in Cincinnati, Ohio. She did a fellowship in neurophysiology at the University of Michigan Medical School in Ann Arbor, Michigan. Dr. Cheshire is double board certified in neurology and clinical neurophysiology. She enjoys traveling, reading and music. She currently resides in Viera, Florida.  Dr. Cheshire joined TeleSpecialists in June 2019.
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Jessica Floyd, MD

Dr. Floyd completed her neurology residency at Mayo Clinic in Jacksonville, Florida followed by fellowship training in clinical neurophysiology with focus in EEG and epilepsy at the Medical University of South Carolina in Charleston, South Carolina. She has particular interest in hospital neurology and patient education as well as the blossoming specialty of lifestyle medicine. She strives to take advantage of every encounter with patients and medical staff to empower them to do their own research into how daily thoughts, choices, and habits can add up to create greater and longer-lasting brain and neurologic health for ourselves and our loved ones. She lives in Florence, South Carolina with her awesome husband of 13 plus years and three beautiful children. She is an avid yogi, astrologer, and lover of food and all things neurology! Dr. Floyd joined the TeleSpecialist family in July 2017.
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Nancy Futrell, MD

Dr. Futrell received her medical degree from the University of Utah in Salt Lake City, Utah. She also did her neurology residency at the University of Utah as well as a research fellowship in cerebral vascular disease at Jackson Memorial Hospital in Miami, Florida. She currently resides in Salt Lake City, Utah. She has authored 2 books and 50 peer reviewed papers. 
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Rebecca Jimenez-Sanders, MD

Dr. Jimenez Sanders received her undergraduate degree from Emory University, and her medical degree from the San Juan Bautista School of Medicine in Puerto Rico. She completed her neurology residency at the University of South Florida in Tampa, Florida, where she also did a specialized headache medicine and facial pain fellowship. She currently resides in Tampa, Florida with her husband and her two daughters. She is also fluent in Spanish and Italian languages, and enjoys photography, baking, boating, and biking.
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Cory Lamar, MD

Dr. Lamar received his medical degree from Meharry Medical College in Nashville, Tennessee. He completed his internship and residency at Wake Forest Baptist Health in Winston Salem, North Carolina. Following residency, he completed a clinical fellowship in neurophysiology, with a concentration in epilepsy. He currently resides in Florida and enjoys outdoor activities.
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Clifford Meyers, MD

Dr. Meyers received his medical degree from Brown University in Providence, Rhode Island and his MBA from the Simon School of Business at the University of Rochester in Rochester, New York. He completed his neurology residency at the University of Rochester, where he also did a neurophysiology fellowship. Dr. Meyers resides in Webster, New York with his wife and daughter. When not doing teleneurology, he enjoys playing sports with his wife and daughter.
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Tao Tong, MD

Dr. Tong received her medical degree from the University of Miami School of Medicine in Miami, Florida. She completed her neurology residency at Jackson Memorial Hospital in Miami, Florida, where she also did a neuromuscular/EMG fellowship.  She currently resides in College Station, Texas. Dr. Tong is married with two boys. She enjoys spending time with her family, traveling and reading.
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Shubhangi Chumble, MD

Dr. Chumble attended BJ Medical School. She is a board certified neurologist with a subspeciality interest in sleep medicine. Dr. Chumble did her residency at Howard University in Washington DC and has practiced neurology since 2001 in private and corporate settings. She lives in Melbourne, Florida and loves the sunshine state. Her hobbies include yoga, meditation, cooking , traveling and meeting new people. She also loves to do stained glass, pottery and painting. She joined TeleSpecialists in June 2019.
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