Neurocritical Care

Unknown (36.1%)

Other (2.6%)

1. Thrombolysis

Alteplase 0.9 mg/kg (maximum 90 mg) within 4.5 hours of symptom onset; 10% of total dose as

intravenous bolus, followed by 90% as 60-minute intravenous infusion.

Tenecteplase 0.25 mg/kg intravenous bolus (maximum 25 mg) within 4.5 hours of symptom onset

may also be considered for off-label use in patients with acute ischemic stroke because it was found

In patients with acute ischemic stroke who awake with stroke symptoms or have unclear time of

onset more than 4.5 hours from last known well, or at baseline state can undergo MRI to help

select those who can benefit from intravenous alteplase administration within 4.5 hours of stroke

(DBP) is less than 105 mm Hg.

Patient Selection Criteria

Patient History Excludes All Contraindications

Onset of symptoms < 4.5 hr from drug

administration

Baseline head CT excludes intracerebral

hemorrhage (ICH) or other risk factors

Age ≥ 18 yr

Vital signs and laboratory values:

INR ≤ 1.7

Plt ≥ 100,000/mm3

Blood glucose > 50 mg/dL

Blood pressure control (SBP < 185 mm Hg,

DBP < 110 mm Hg)

Intracranial or intraspinal surgery within 3 mo

Head trauma or stroke < 3 mo

Active internal or intracerebral bleeding

Symptoms suggestive of SAH

Any history of ICH

Intracranial neoplasm, arteriovenous malformation, or aneurysm

Arterial puncture at noncompressible site within 1 wk

Current SBP > 185 mm Hg or DBP > 110 mm Hg

Current use of anticoagulant agents with evidence of elevated

sensitive laboratory tests, including direct-acting oral anticoagu-

lants and therapeutic doses of low-molecular-weight heparin

Additional exclusion criteria for 3- to 4.5-hr window:

NIHSS > 25

Current treatment with PO anticoagulants (regardless of INR)

Evidence of ischemic injury > 1/3 of MCA territory

aExclusions are primarily based on the risk of systemic bleeding or hemorrhagic conversion of stroke.

DBP = diastolic blood pressure; MCA = middle cerebral artery; NIHSS = NIH Stroke Scale (score); SBP = systolic blood pressure; tPA = tissue plasminogen activator.

Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008;359:1317-29. Demaerschalk BM,

Kleindorfer DO, Adeoye OM, et al. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for

healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2016;47:581-641. Powers WJ, Rabinstein AA, Ackerson T, et al.

2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American

Stroke Association. Stroke 2018;49:e46-e99. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke:

2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/

American Stroke Association. Stroke 2019;50:e344-e418.

Reduction in blood pressure after thrombolysis or recanalization is reasonable within the first 24

hours after the onset of stroke.