Stroke fibrinolysis checklist

Background (Summary 2007 NICE guideline)

  • Alteplase is recommended for the treatment of acute ischaemic stroke when used by physicians trained and experienced in the management of acute stroke
  • Alteplase has a marketing authorisation for the fibrinolytic treatment of acute ischaemic stroke
  • Treatment must be started within 4.5 hours of onset of the stroke symptoms and after prior exclusion of intracranial haemorrhage by means of appropriate imaging techniques
  • Alteplase is not indicated for the treatment of acute stroke in children aged under 18 years or adults aged over 80 years
  • The recommended dose of alteplase for the treatment of acute ischaemic stroke is 0.9 mg alteplase/kg body weight (maximum of 90 mg) [NICE technology appraisal guidance 122 4 ] infused intravenously over 60 minutes, with 10% of the total dose administered as an initial intravenous bolus
  • Alteplase manufacturer identified six relevant robust trials (RCTs) of alteplase in the treatment of acute ischaemic stroke (NINDS I and II, n = 624; ATLANTIS A, n = 142; ATLANTIS B, n = 613; ECASS I, n = 620; and ECASS II, n = 814). The manufacturer’s submission draws on evidence from the Cochrane Review (2003), which was an overall meta-analysis of the use of thrombolytics for acute ischaemic stroke. There is a statistically significant difference (odds ratio [OR] 0.64; 95% confidence interval [95% CI] 0.50 to 0.83) favouring treatment with alteplase in terms of the outcome of death or dependency at 3 months
  • The incidence of intracranial haemorrhage was increased in patients receiving alteplase

American Heart association Stroke Fibrinolytic checklist

Cincinnati PreHospital Stroke Scale

Facial Droop

  • Normal
  • Abnormal

Arm Drift

  • Normal
  • Abnormal (± pronator drift)

Abnormal Speech "you can’t teach an old dog new tricks"

  • Normal – correct words no slurring
  • Abnormal - slur words, wrong words, unable to speak


Any 1 of 3 signs is abnormal = 72% probability of stroke

 tPA in Acute Ischaemic Stroke- All boxes must be checked before tPA can be considered.

Inclusion Criteria (all must apply)

  • Age 18 years or older?
  • Clinical Dx of ischaemic stroke with a measurable neurological deficit?
  • Time of symptom onset (when patient was last seen normal) well established as <180 minutes (3 hours) before treatment would begin?

Exclusion Criteria (NONE must apply)

  • Evidence of intracranial haemorrhage on pretreatment noncontrast head CT?
  • Clinical presentation suggestive of subarachnoid haemorrhage even with normal CT?
  • CT shows multilobar infarction (hypodensity greater than one third cerebral hemisphere)?
  • History of intracranial haemorrhage?
  • Uncontrolled hypertension: SBP > 185 mm Hg or DBP>110 mm Hg despite repeated measurements?
  • Known arteriovenous malformation, neoplasm, or aneurysm?
  • Witnessed seizure at stroke onset?
  • Active internal bleeding or acute trauma (fracture)?
  • Acute bleeding diathesis, including:
    • Platelet count <100 000/mm3? 
    • Heparin received within 48 hours
    • Current use of anticoagulant with INR >1.7 or prothrombin time PT >15 seconds?*
  • Within 3 months of intracranial or intraspinal surgery, serious head trauma, or previous stroke?
  • Arterial puncture at a noncompressible site within past 7 days?
  • Only minor or rapidly improving stroke symptoms (clearing spontaneously)
  • Within 14 days of major surgery or serious trauma
  • Recent gastrointestinal or urinary tract haemorrhage (within previous 21 days)
  • Recent acute myocardial infarction (within previous 3 months)
  • Post myocardial infarction pericarditis
  • Abnormal blood glucose level (<50 or >400 mg/dL [<2.8 or >22.2 mmol/L])*
  • In patients without recent use of oral anticoagulants or heparin, treatment with tPA can be initiated before availability of coagulation study results but should be discontinued if the INR is >1.7 or the partial thromboplastin time is elevated by local

Approach to high BP in stroke

Please see Hypertension in Stroke page.

Content by Dr Íomhar  O' Sullivan 04/01/2007. Reviewed by Dr ÍOS 03/02/2008, 22/05/2009. Last review Dr ÍOS 15/06/21