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)