Wechlser listed exclusion criteria for therapy with intravenous tissue plasminogen activator (t-PA) for a patient with an ischemic stroke. These can help to identify patients more likely to benefit from the therapy than to suffer a serious complication. The criteria are based on those of Jauch et al. The author is from the University of Pittsburgh.


Intravenous therapy with tissue plasminogen activator (t-PA) may not be appropriate if:

(1) the patient does not meet inclusion criteria

(2) the patient has absolute contraindications

(3) the patient has relative contraindications AND risk outweighs benefits


Inclusion criteria - all of the following:

(1) diagnosis of acute ischemic stroke

(2) age of the patient >= 18 years

(3) onset of symptoms

(3a) < 3 hours prior to start of t-PA infusion OR

(3b) 3 to 4.49 hours prior to start of t-PA infusion in selected patients


Absolute exclusion criteria:

(1) head trauma <= 90 days prior to starting infusion

(2) stroke <= 90 days prior to starting infusion

(3) arterial puncture at a noncompressible site <= 7 days prior to starting infusion

(4) history of intracranial hemorrhage

(5) elevated blood pressure unresponsive to antihypertensive therapy (with systolic blood pressure >= 185 mm Hg OR diastolic pressure >= 110 mm Hg)

(6) evidence of active bleeding

(7) acute coagulopathy with one or more of the following:

(7a) thrombocytopenia with platelet count <= 100,000 per µL

(7b) oral anticoagulation with INR >= 1.7

(7c) heparin therapy within the previous 48 hours AND elevated aPTT

(8) hypoglycemia with blood glucose < 2.7 mmol/L (< 50 mg/dL)

(9) head CT shows hypodensity involving more than one third of a cerebral hemisphere (multilobar infarct)


Relative contraindications:

(1) evidence of a minor stroke OR stroke with improving symptoms (spontaneous clearing)

(2) seizure at onset of stroke AND postictal residual neurologic impairments

(3) major trauma or major surgery <= 14 days prior to starting infusion

(4) urinary or gastrointestinal tract bleeding <= 21 days prior to starting infusion

(5) acute myocardial infarction (AMI) <= 90 days prior to starting infusion


The final decision to treat depends on a careful analysis of the individualized cost-to-benefit ratio and informed consent.


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