• Patients of any age with suspected ischemic stroke within 4.5 hours of last known well.
• Selected patients beyond 4.5 hours from last known well, with unwitnessed time of onset.
• See more details regarding eligibility criteria below (GWTG Goal Times).

Within 4.5 hrs:

• No upper age limit
• SBP <185 or DBP <110 (see pretreatment recommendations below)

Exclusions:

• CT brain imaging exhibits extensive regions of clear hypoattenuation
• Ischemic stroke within 3 months
• Severe head trauma within 3 months
• Intracranial/intraspinal surgery within 3 months
• History of intracranial hemorrhage
• Suspected subarachnoid hemorrhage
• GI malignancy or recent GI bleed
• Platelets <100 000/mm3, INR >1.7, aPTT >40 s, or PT >15 s
• LMWH within 24 hours
• DOAC within 48 hours
• High suspicion of infectious endocarditis
• Suspected aortic dissection
• Suspected intra-axial intracranial neoplasm

Beyond 4.5 hours from last known well (based on published WAKE UP trial: https://www.nejm.org/doi/full/10.1056/NEJMoa1804355)

• Unwitnessed event (recognized symptoms upon awakening or unable to report timing of onset due to, for example, confusion or aphasia)
• MRI suggestive of more recent onset of event (Based on MRI-DWI positivity and FLAIR negativity
• Note that acute MRI may be challenging to obtain in some practice environments and this may limit eligibility by this criteria.
• Age up to 80 years and functionally independent
• No LVO; LVO patients are prioritized for EVT
• Not severe stroke (NIHSS <=25)
• Meets other standard IV thrombolytic eligibility other than time from last known well

• Determine “Last Known Well” time WITHIN 5 MIN OF ED ARRIVAL
• Activate Stroke Team (513-584-8282) WITHIN 10 MIN OF ED ARRIVAL
• Perform non-contrast CT scan and CTA (head/neck) WITHIN 20 MIN OF ED ARRIVAL
• Draw bloods for lab tests (CBC, renal, coags, pregnancy, fingerstick glucose).
• Obtain fingerstick glucose promptly to determine IV thrombolytic eligibility.
• Do not delay thrombolytic for other lab results unless clinical suspicion of abnormality.
• Establish two IV lines.
• Record blood pressure.
• Gently treat (usually labetalol 10 mg to start, assuming no clinical contraindications) if ≥185 systolic or ≥110 diastolic if potential IV thrombolytic candidate (details below).
• Review eligibility criteria for IV thrombolytic (details below)
• Interpret CT scan -- rule out bleed or subacute ischemia WITHIN 35 MIN OF ARRIVAL
• Start IV thrombolytic bolus if eligible. WITHIN 45 MIN OF ARRIVAL

• Tenecteplase (TNKase) - 0.25mg/kg (maximum 25mg). Administer as a bolus over 5 seconds, followed by a 10mL bolus of 0.9% sodium chloride (NS).
• OR, if tenecteplase is not available, use alteplase (Activase) - 0.9 mg/kg dose (maximum 90 mg). Administer 10% as bolus over 1-2 minutes and the remainder as an infusion over 60 minutes.
• Do not use the cardiac dose.
• Do not exceed the maximum dose.
• Use rt-PA = tenecteplase = TNKase. Do not use other thrombolytic agents. Use alteplase (Activase) only if tenecteplase is unavailable in the adult population. Note that the dose is different for each IV thrombolytic (see above).
• Do not give aspirin, clopidogrel, heparin, warfarin or other oral anticoagulants for the first 24 hours after IV rt-PA.

• Potential IV thrombolytic candidates should not receive antiplatelets (aspirin, clopidogrel) or anticoagulants (heparin, warfarin, or DOACs) upon arrival to ED.
• However, patients who have taken antiplatelets prior to arrival in the Emergency Department are still considered IV thrombolytic candidates and those taking anticoagulant medications may still be candidates as well.
• At 24 +/- 6 hours, a non-contrast CT scan or MRI should be performed (to rule out any intracranial hemorrhage) before starting an antiplatelet or anticoagulant medication.

Consider transfer to a Neuroscience Intensive Care Unit for patients needing specialized monitoring and management including:

• Severe (NIHSS ≥10) stroke with risk of malignant MCA syndrome requiring anticipation and consideration of decompressive hemicraniectomy by neurosurgery
• Cerebellar stroke with risk of malignant edema requiring anticipation and consideration of posterior decompression by neurosurgery
• Fluctuating neurological symptoms requiring specialized blood pressure management.
  Hold infusion and repeat head CT stat
• Large vessel occlusion that may require endovascular measures in upcoming hours, given the higher risk of neurological deterioration.

Admit patient to ICU and follow post-IV thrombolytic order set, including:

• Monitor BP and neuro status:
  Q15 min X 2 hours, q30 min X 6 hours, then q1 hour X 16 hours
• Treat SBP≥180 or DBP ≥105 (details below)
• Call stroke physician at 513-584-8282 if there is a decline in neuro status, new headache, nausea, or vomiting.
• Hold infusion and repeat head CT stat
• NPO until swallowing assessed
• DVT prophylaxis with intermittent stocking compression devices (SCDs) but no anticoagulants

Consider transfer to a Neuroscience Intensive Care Unit for patients needing specialized monitoring and management including:

• Severe (NIHSS ≥10) stroke with risk of malignant MCA syndrome requiring anticipation and consideration of decompressive hemicraniectomy by neurosurgery.
• Cerebellar stroke with risk of malignant edema requiring anticipation and consideration of posterior decompression by neurosurgery.
• Fluctuating neurological symptoms requiring specialized blood pressure management.
• Hold infusion and repeat head CT stat
• LVO that may require endovascular measures in upcoming hours, given the higher risk of neurological deterioration.

For IV thrombolytic candidates: BP should be brought to SBP <185 mmHg or DBP <110 mmHg if possible. This must be done without aggressive antihypertensive treatment for the patient to remain eligible for IV thrombolytic. If blood pressure remains ≥185 systolic or ≥110 diastolic with nonaggressive measures (rarely), then the patient is not eligible for IV thrombolytic.

• BP MANAGEMENT PRIOR TO IV THROMBOLYTIC ADMINISTRATION
  1. Up to two of the following agents may be used for nonaggressive treatment:
  2. Labetalol 10 to 20 mg IV over 1-2 minutes, may repeat X 1 (max dose 40 mg)
  3. Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5-15-minute intervals (up to max dose 15 mg/h; when desired BP attained, reduce to 3 mg/h)
  4. Enalaprilat 0.625 to 1.25 mg IV (up to max dose of 1.25 mg)
  5. Hydralazine 10 mg IV over 1-2 minutes, may repeat X1 (max dose 20 mg)
  6. Nitropaste 1 to 2 inches (up to max dose of 2 inches)
• If IV thrombolytic not planned, then permissive HTN up to 220/120 may be reasonable

During/after treatment with thrombolytic or other acute reperfusion intervention, BP must be aggressively maintained at SBP <180 or DBP <105 BP should be brought to SBP <185 mmHg or DBP <110 mmHg if possible. This must be done without aggressive antihypertensive treatment for the patient to remain eligible for IV thrombolytic. If blood pressure remains ≥185 systolic or ≥110 diastolic with nonaggressive measures (rarely), then the patient is not eligible for IV thrombolytic.

• Monitor BP every 15 minutes for first 2 hours, then every 30 minutes for next 6 hours, then every hour for the next 16 hours.
• Monitor blood pressure every 15 minutes during the antihypertensive therapy. Observe for hypotension.
  
  BLOOD PRESSURE MANAGEMENT DURING/AFTER ADMINISTERING IV thrombolytic
  If systolic BP ≥180–230 mm Hg or diastolic BP ≥105–120 mm Hg:
  • Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min; or
  • Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5–15 minutes, maximum 15 mg/h
  If BP not controlled or diastolic BP >140 mm Hg: Consider IV sodium nitroprusside

• Management of sICH after thrombolysis is the same with tenecteplase as it is with alteplase.
• If an sICH is suspected, the treating stroke physician 513-584-8282 should be contacted IMMEDIATELY.
• Suspect sICH if there is any acute neurological deterioration (new headache, acute hypertension, seizure, or nausea and vomiting) or acute increase in BP.
• If hemorrhage is suspected, then do the following:
  
  

• If angioedema is suspected, the treating stroke physician (513-584-8282) should be contacted IMMEDIATELY.
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