| Inclusion Criteria |
- A significant neurologic deficit expected to result in long-term disability
- Noncontrast CT scan showing no hemorrhage or well-established new infarct
- Acute ischemic stroke symptoms with the patient last known well, clearly defined, less than 3 h before rt-PA will be given
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| Contraindications |
- SBP greater than 185 or DBP greater than 110 mmHg (despite measures to reduce it)
- CT findings (intracranial hemorrhage, subarachnoid hemorrhage, or major infarct signs)
- Platelets less than 100,000, PTT greater than 40 s after heparin use, or PT greater than 15 or INR greater than 1.7, or known bleeding diathesis
- Recent surgery/trauma (less than 15 d)
- Seizure at onset (with postictal impairments)
- Active internal bleeding (less than 22 d)
- Recent intracranial or spinal surgery, head trauma, or stroke (less than 3 mo)
- History of intracranial hemorrhage or brain aneurysm or vascular malformation or brain tumor
- Suspicion of subarachnoid hemorrhage
|
| Warnings (conditions that might lead to unfavorable outcomes) |
- Stroke severity too mild
- Rapid improvement
- Stroke severity—too severe (e.g., NIHSS greater than 22) [Many centers do not exclude patients based on an increased NIHSS alone]
- Glucose less than 50 or greater than 400 mg/dL
- Life expectancy less than 1 y or severe comorbid illness or CMO on admission
- Increased risk of bleeding
- Subacute bacterial endocarditis
- Hemostatic defects including those secondary to severe hepatic or renal disease
- Diabetic hemorrhage retinopathy, or other hemorrhagic ophthalmic conditions
- Septic thrombophlebitis or occluded AV cannula at seriously infected site
- Patients currently receiving oral anticoagulants, e.g., warfarin sodium
- Increased risk of bleeding due to pregnancy
- Advanced age (increased risk of bleeding)
- Documented left heart thrombus
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| From the Massachusetts General Hospital Acute Stroke Services. |