Table 1 Official indications and contraindications for Alteplase in acute stroke treatment

Indications

 Diagnosis of ischemic stroke causing a measurable disabling neurologic deficit

 Onset of symptoms < 4.5 h before beginning treatment

 Age ≥ 16 years

Clear contraindications

 Severe head trauma in previous 3 months

 Symptoms suggestive of subarachnoid hemorrhage

 Previous ICH

 Intracranial/spinal surgery in previous 3 months

 Intracerebral neoplasm

 Infective endocarditis

 Aortic arch dissection

 Elevated blood pressure (systolic > 185 mm Hg or diastolic > 110 mm Hg) that cannot be lowered safely

 Active internal bleeding

 Acute bleeding diathesis, including but not limited to:

  Platelet count < 100,000/mm³

  Heparin received within 48 h with an elevated aPTT (> 40 s)

  Current use of treatment doses of low-molecular-weight heparin within the previous 24 h (not applicable to DVT prophylactic dosages of low-molecular-weight heparin)

  Current use of anticoagulant with INR > 1.7 or PT > 15 s

  Current use of direct thrombin inhibitors or direct factor Xa inhibitors

 CT demonstrates infarction (hypodensity) > 1/3 cerebral hemisphere

 CT demonstrates an acute ICH

Relative contraindications

 Mild and nondisabling or rapidly improving stroke symptoms

 Very severe neurologic deficits (NIHSS score > 25) within the 3- to 4.5 h window

 Pregnancy

 Seizure at onset (consider Alteplase if neurologic deficits are thought to be caused by a stroke)

 Arterial puncture at non-compressible site in previous 7 days

 Untreated intracranial arteriovenous malformation

 Untreated giant intracranial aneurysm

 Recent major surgery or serious trauma (within previous 14 days)

 Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)

 Ischemic stroke within previous 3 months

 Recent ST-elevation acute myocardial infarction (within previous 3 months)

 Blood glucose concentration < 50 mg/dL (2.7 mmol/L)