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.
