Thrombolysis inclusion/exclusion criteria

Inclusion Criteria - The Green Light

• Age ≥ 18 years
• Clinical diagnosis of ischemic stroke causing measurable neurological deficit.
• Time from symptom onset to treatment is within 3 hours (standard window).
• An extended window of up to 4.5 hours is available for a select patient group.
• Blood pressure is controlled to <185/110 mmHg prior to and during IV alteplase administration.

⭐ The extended 3 to 4.5-hour window has stricter exclusion criteria, including: age > 80 years, NIHSS score > 25, or a history of both diabetes and prior ischemic stroke.

Exclusion Criteria - Absolute No-Gos

• Hemorrhage:
  • Any prior Intracranial Hemorrhage (ICH)
  • Active internal bleeding
  • Known intracranial aneurysm, AVM, or neoplasm
• Recent Major Events (Time-Sensitive):
  • Intracranial/intraspinal surgery or serious head trauma within 3 months
  • Major non-head surgery or serious trauma within 14 days
• Vitals & Labs:
  • Persistent BP > 185/110 mmHg despite treatment
  • Platelet count < 100,000/mm³
  • INR > 1.7 or elevated aPTT
• Specific Conditions:
  • Suspected aortic arch dissection
  • Infective endocarditis

⭐ Even if a patient's blood pressure is initially >185/110 mmHg, thrombolysis can be considered if the BP can be safely lowered and maintained below this threshold with medication.

Time Windows - The Ticking Clock

• "Time is Brain": The single most critical factor. The clock starts from the patient's Last Known Normal (LKN).
• Efficacy of IV thrombolysis is strictly time-dependent.

• 0-3 Hours (Golden Window)
  • Highest benefit from IV Alteplase.
• 3-4.5 Hours (Extended Window)
  • Stricter exclusion criteria apply:
    • Age > 80 years
    • Severe stroke (NIHSS > 25)
    • History of both diabetes and prior ischemic stroke
    • On any oral anticoagulant (regardless of INR).

⭐ The DAWN and DEFUSE-3 trials proved the benefit of mechanical thrombectomy for Large Vessel Occlusion (LVO) up to 24 hours post-LKN, using perfusion imaging to identify salvageable brain tissue.

High‑Yield Points - ⚡ Biggest Takeaways

• Time is critical: Administer tPA within 3 hours of symptom onset; can extend to 4.5 hours in select patients.
• BP must be <185/110 mmHg before and during infusion.
• Absolute contraindications include any prior intracranial hemorrhage (ICH), active bleeding, or arteriovenous malformation.
• Exclude for recent (<3 months) major surgery, serious head trauma, or prior stroke.
• Bleeding diathesis is a key exclusion: Platelets <100,000, elevated INR, or recent anticoagulant use.
• CT findings: Exclude for signs of hemorrhage or a large established infarct (>1/3 hemisphere).