Thrombolytic therapy for ischemic stroke. An example of exclusion criteria as used in Hamilton Health Sciences

Table 12.4-5. Thrombolytic therapy for ischemic stroke. An example of exclusion criteria as used in Hamilton Health Sciences
Exclusion criteria for thrombolytic therapy with rtPA for acute stroke order set Goal: Door-to-needle time: 60 minutes
Absolute exclusion criteria: All answers must be “NO”
Onset of symptoms or the “last seen normal” is >4.5 h	Yes	No
CT evidence of cerebral hemorrhage	Yes	No
Clinical presentation consistent with subarachnoid hemorrhage even if CT scan normal	Yes	No
Blood pressure >185/110 mm Hg and not treatable	Yes	No
Blood glucose level <2.7 mmol/L (48.6 mg/dL)	Yes	No
Significant head trauma, brain surgery, or spinal surgery within 3 months	Yes	No
History of intracranial hemorrhage (in previous 6 months)	Yes	No
Recent minor stroke (1 month) or moderate to severe stroke (3 months)	Yes	No
Active internal, gastrointestinal, or urinary bleeding within 21 days	Yes	No
Arterial puncture at a noncompressible site in previous 7 days	Yes	No
Platelet count <100×109/L	Yes	No
IV heparin received within 48 h, resulting in abnormally elevated aPTT >40 s	Yes	No
Low-molecular-weight heparin at full anticoagulant levels	Yes	No
Warfarin use with INR >1.7	Yes	No
Direct oral anticoagulants (rivaroxaban, dabigatran, apixaban) taken within previous 48 ha	Yes	No
Relative contraindications: Consider eligibility on an individual basis based on benefits and risks
Rapidly improving neurologic signs or NIHSS <4	Yes	No
History of arteriovenous malformation or aneurysm	Yes	No
Profound stroke with obtundation, fixed eye deviation, and complete hemiplegia, or NIHSS >24	Yes	No
Acute cerebral infarct with ASPECTS ≤5	Yes	No
Recent large myocardial infarction or pericarditis within 3 months	Yes	No
Blood glucose level >22.2 mmol/L (399.6 mg/dL)	Yes	No
Recent major surgery or trauma (cardiac, thoracic, abdominal, orthopedic) within 14 days	Yes	No
History of bleeding diathesis or liver failure	Yes	No
Seizure at onset of stroke with residual postictal neurologic deficits	Yes	No
Pregnancy	Yes	No
Age <18 years	Yes	No
Summary eligibility assessment: All answers must be checked
1. The patient meets inclusion criteria: acute ischemic stroke symptom and symptom onset <4.5 h.	Yes	No
2. The patient does not have any of the absolute exclusion criteria.	Yes	No
3. The patient may have one or more of the relative contraindications, but potential benefits of alteplase exceed potential risks.	Yes	No
Alteplase (rtPA) to be given (YES or NO):	Yes	No
a Some experts consider the reversal of dabigatran with idarucizumab and the use of rtPA in selected patients.Evidence 36Strong recommendation (benefits clearly outweigh downsides; right action for all or almost all patients). High Quality of Evidence (high confidence that we know true effects of the intervention). Wardlaw JM, Murray V, Berge E, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet. 2012 Jun 23;379(9834):2364-72. Doi: 10.1016/S0140-6736(12)60738-7. Epub 2012 May 23. Review. PMID: 22632907; PMCID: PMC3386494. Wardlaw JM, Murray V, Berge E, del Zoppo GJ. Thrombolysis for Acute Ischemic Stroke, Update August 2014. Stroke. 2014;45(11):e222-e225. doi: 10.1161/STROKEAHA.114.007024. Berge E, Whiteley W, Audebert H, et al. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J. 2021 Mar;6(1):I-LXII. doi: 10.1177/2396987321989865. Epub 2021 Feb 19. PMID: 33817340; PMCID: PMC7995316.
aPTT, activated partial thromboplastin time; ASPECTS, Alberta Stroke Program Early CT Score; CT, computed tomography; INR, international normalized ratio; NIHSS, National Institutes of Health Stroke Scale; PO, oral; rtPA, recombinant tissue plasminogen activator.