Hospital Pharmacy - February 2020 - 21

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Armahizer et al
Table 4. Indications and Contraindications for the Use of IV Alteplase for Management of Acute Ischemic Stroke.2
Indications
Time from stroke-symptom onset
0 to 3 hours
(FDA approved and ASA/AHA
guideline recommended)
3 to 4.5 hours
(ASA/AHA guideline
recommended)

Eligibility criteria
**
**
**
**
**
*
**
**
**

Disabling AIS symptoms (mild to severe)
≥18 years old
Early ischemic changes observed on head CT
Initial blood glucose > 50 mg/dL
Otherwise medically eligible
In addition to the above:
NIHSS ⩽ 25
Not taking DOAC
Ischemic injury < 1/3 of MCA territory

Comments
** Benefits outweigh risks for eligible
patients taking single or dualantiplatelet therapy
** Benefits outweigh risks for eligible
patients with ESRD and a normal aPTT
** IV alteplase is not recommended if >
4.5 hours after stroke onset

Contraindications
FDA labeled contraindications
** Current severe uncontrolled
hypertensiona
** Active ICH, SAH, or internal
bleeding
** Recent intracranial/intraspinal
surgery or severe head trauma
(within 3 months)
** Intracranial neoplasm, AV
malformation, aneurysm
** Bleeding diathesis

AHA/ASA acute stroke guideline
contraindications
** Extensive hypoattenuation on CT brain
imaging
** Recent AIS (within 3 months)
** Posttraumatic infarction secondary to head
injury
** Active internal bleeding
** Coagulopathyb
3
* Platelets < 100/m
* INR > 1.7
* aPTT > 40 s
* PT > 15 s
** Received therapeutic dose of LMWH within
24 hours
** Received DOAC within 48 hours
** AIS secondary to infective endocarditis
** AIS secondary to aortic arch dissection

High-risk populations
** Risk vs benefits must be outweighed
in patients with the following
characteristics:
** Moderate to severe AIS that improved,
but has deficits
** Seizures secondary to AIS
** Pregnancy
** Dural puncture (within 7 days)
** Arterial puncture of noncompressible
blood vessel (within 7 days)
** Active menstruation
** Cerebral microbleeds on MRI
(especially if > 10)
** Concurrent acute MI
** Recent MI (within 3 months)
** Acute pericarditis
** Systemic malignancy
** History of hemorrhagic ophthalmic
conditions

Note. IV = intravenous; FDA = Food and Drug Administration; ASA = American Stroke Association; AHA = American Heart Association;
AIS = acute ischemic stroke; CT = computed tomography; ESRD = end-stage renal disease; aPTT = activated partial thromboplastin time;
NIHSS = National Institutes of Health Stroke Scale; DOAC = direct oral anticoagulant; MCA = middle cerebral artery; ICH = intracerebral
hemorrhage; SAH = subarachnoid hemorrhage; AV = arteriovenous; INR = international normalized ratio; PT = partial thromboplastin;
LMWH = low molecular weight heparin; MRI = magnetic resonance imaging; MI = myocardial infarction; BP = blood pressure.
a
IV alteplase can be used if BP is lowered safely with antihypertensive agents, with physician assessment of BP stability. General recommendation is to
maintain BP < 185/110 prior to initiation of alteplase.
b
Patients without thrombocytopenia history can initiate IV alteplase before platelet count results, but should be discontinued if <100/m3. Without recent
oral anticoagulant or heparin use, can initiate before availability of coagulation tests, but should be discontinued if INR > 1.7 or PT is abnormally elevated.

(STK-6). Given the importance of these measures to accreditation as a Comprehensive Stroke Center, pharmacists
managing the care of stroke patients should be aware of
these measures and provide therapeutic recommendations to
improve adherence.

Conclusion
The management of patients presenting with AIS, especially
those caused by LVO, continues to evolve. The utilization of
endovascular therapies will continue to increase in the coming

years, with additional research likely identifying specific areas
of practice that continue to remain controversial, such as acute
blood pressure management. Pharmacists and pharmacy
departments caring for AIS patients should continue to develop
standard practice guidelines for their individual institutions to
ensure they remain compliant with Joint Commission standards for stroke centers.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
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