Efficacy and Safety of i.v. Alteplase Therapy up to 4.5 Hours after Acute Ischemic Stroke Onset

Authors and Disclosures

Jenna L. Otwell, Haley M. Phillippe and Kelly S. Dixon

Jenna L. Otwell, Pharm.D., is Postgraduate Year 1 Pharmacy Practice Resident, East Alabama Medical Center and Harrison School of Pharmacy, Auburn University, Opelika, AL. Haley M. Phillippe, Pharm.D., BCPS, is Assistant Clinical Professor and Ambulatory Care Clinical Pharmacist, Harrison School of Pharmacy, Auburn University, Owens Cross Roads, AL. Kelly S. Dixon, Pharm.D., is Neurology Intensive Care Clinical Pharmacist, Huntsville Hospital, Huntsville, AL

Address correspondence
Dr. Phillippe at the Harrison School of Pharmacy, Auburn University, 114 Simmons Drive SE, Owens Cross Roads, AL 35763 (mccrahl@auburn.edu).

Appendix—Inclusion and Exclusion Criteria for Thrombolytic Treatment with Alteplase in Acute Ischemic Stroke (AIS)^[2,4,6]

Inclusion Criteria

• Ageof ≥18 years

• Clinical diagnosis of ischemic stroke

• Onset of stroke symptoms within previous three hours

• Baseline computed tomography (CT) or magnetic resonance imaging (MRI) showing no evidence of intracerebral hemorrhage (ICH)

Exclusion Criteria

• Minor or rapidly improving stroke symptoms

• Evidence of ICH on pretreatment evaluation (via CT or MRI)

• History of ICH, arteriovenous malformation, or aneurysm

• High clinical suspicion of subarachnoid hemorrhage even if CT scan is normal

• Witnessed seizure at stroke onset

• Intracranial surgery, serious head trauma, or previous stroke within previous three months

• Major surgery or serious trauma within two weeks

• Active internal bleeding (including any gastrointestinal or genitourinary bleeding) within previous three weeks

• Systolic blood pressure of >185 mm Hg or diastolic blood pressure of >110 mm Hg

• Serum glucose of <50 or >400 mg/dL

• Arterial puncture at a noncompressible site or lumbar puncture within previous week

• Platelet count of <100,000/mm³

• Administration of heparin within 48 hours and elevated activated partial thromboplastin time

• Current use of oral anticoagulants and an International Normalized Ratio (INR) of >1.7

• Recent acute myocardial infarction (or clinical presentation suggesting postmyocardial infarction pericarditis)

• Currently pregnant

Additional Exclusion Criteria for Patients Treated 3–4.5 Hours after AIS Symptom Onset

• Age of >80 years

• Current use of oral anticoagulants (regardless of INR)

• Baseline National Institutes of Health Stroke Scale score of >20

• Medical history of both stroke and diabetes