Patient selection for intravenous thrombolytic therapy in acute ischemic stroke

IVT with alteplase or tenecteplase is the mainstay of treatment for acute ischemic stroke. Because the benefit of treatment is time dependent, it is critical to treat patients as quickly as possible. The SBP/DBP must be <185/110 mmHg before starting IVT and must be <180/105 mmHg for 24 hours following IVT. Refer to relevant UpToDate topics for full details of IVT including dosing and administration, potential adverse effects, and post-treatment management.

IVT: intravenous thrombolysis; NCCT: noncontrast computed tomography; MRI: magnetic resonance imaging; DWI: diffusion-weighted MRI; FLAIR: fluid-attenuated inversion recovery; CT: computed tomography; CTP: CT perfusion; PWI: perfusion-weighted MRI; CTA: CT angiogram; SBP: systolic blood pressure; DBP: diastolic blood pressure; INR: international normalized ratio; aPTT: activated partial thromboplastin time; DOAC: direct oral anticoagulant; LMWH: low molecular weight heparin; VTE: venous thromboembolism.

* An MRI mismatch, defined by an acute ischemic brain lesion detected on DWI but no corresponding hyperintensity on FLAIR (diffusion positive and FLAIR negative), correlates with a stroke onset time of 4.5 hours or less, and therefore with IVT eligibility.

¶ Automated perfusion imaging reveals an ischemic core with a larger penumbra of hypoperfused but viable brain tissue.

Δ Refer to UpToDate content on mechanical thrombectomy for acute ischemic stroke.

◊ IVT should NOT be delayed while coagulation tests are pending unless (1) there is clinical suspicion of a bleeding abnormality or thrombocytopenia, (2) the patient is currently on or has recently received anticoagulants (eg, heparin, warfarin, DOAC), or (3) use of anticoagulants is not known. Otherwise, treatment with IVT can be started before availability of coagulation test results.

§ Platelet count should be checked only if there is clinical suspicion for thrombocytopenia.

¥ Patients may be treated with IVT if glucose level is subsequently normalized without reversal of neurologic deficit.

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Patient selection for intravenous thrombolytic therapy in acute ischemic stroke