IV- 16 Circulation December 13. 2005 TABLE 3. Fibrinolytic Checklist Use of tPA in Patients with Acute ischemic stroke All boxes must be checked before tpA can be given. Note: The following checklist includes FDA-approved indications and contraindications for tPA administration for acute ischemic stroke. A physician with xpertise in acute stroke care may modify this list. Inclusion Criteria (all Yes boxes in this section must be checked 口Age18 years or older? B Clinical diagnosis of ischemic stroke with a measurable neurologic deficit? B Time of symptom onset (when patient was last seen normal) well established as <180 minutes(3 hours) before treatment would begin? Exclusion Criteria (all No boxes in "Contraindications section must be checked Contraindications. D Evidence of intracranial hemorrhage on pretreatment noncontrast head CT? a Clinical presentation suggestive of subarachnoid hemorrhage even with normal CT? B CT shows multilobar infarction(hypodensity greater than one third cerebral hemisphere)? B History of intracranial hemorrhage? B Uncontrolled hypertension: At the time treatment should begin, systolic pressure remains >185 mm Hg or diastolic pressure remains >110 mm Hg despite repeated measurements? a Known arteriovenous malformation, neoplasm, or aneurysm? a Witnessed seizure at stroke onset? B Active internal bleeding or acute trauma(fracture)? J Acute bleeding diathesis, including but not limited to -Platelet count <100 000/mm3? -Heparin received within 48 hours, resulting in an activated partial thromboplastin time(aPii) that is greater than upper limit of normal for laboratory? -Current use of anticoagulant (eg, warfarin sodium)that has produced an elevated international normalized ratio (NR)>1.7 or prothrombin time(Pn)>15 seconds?* B Within 3 months of intracranial or intraspinal surgery, serious head trauma, or previous stroke? Relative Contraindications/Precautions experience suggests that under some circumstances--with careful consideration and weighing of risk-to-benefit ratio--patients may receive fibrinolytic despite one or more relative contraindications. Consider the pros and cons of tPa administration carefully if any of these relative contraindications is e Only minor or rapidly improving stroke symptoms (clearing spontaneously) Within 14 days of major surgery or serious trauma Recent gastrointestinal or urinary tract hemorrhage(within previous 21 days) Recent acute myocardial infarction(within previous 3 months) e Postmyocardial infarction pericarditis Abnormal blood glucose level (<50 or >400 mg/dL[<2.8 or >22.2 mmoVLD o 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 scontinued if the INR is >1.7 or the partial thromboplastin time is elevated by local laboratory standards fying that improved outcomes in the tPA treatment arm dence to avoid all delays and treat patients as soon as persist even when imbalances in the baseline stroke possible. Failure to adhere to protocol is associated with an severity among treatment groups is corrected. 70 increased rate of complications, particularly the risk of Administration of Iv tPA to patients with acute ischemic symptomatic intracranial hemorrhage. 71.73 stroke who meet the NINDs eligibility criteria is recom- Community hospitals have reported outc mended if tPA is administered by physicians in the setting of to the results of the NINDS trials after implementing a stroke a clearly defined protocol, a knowledgeable team, and insti- program with a focus on quality improvement. 61, 74,75 The tutional commitment( Class D). It is important to note that the experience of the Cleveland Clinic system is instructive. 71.75 superior outcomes reported in both community and tertiary A quality improvement program increased compliance with care hospitals in the NINds trials have been difficult to the tPA treatment protocol in 9 community hospitals, and the replicate in hospitals with less experience in, and institutional rate of symptomatic intracerebral hemorrhage fell from commitment to, acute stroke care. 71, 72 There is strong evi- 13. 4% to 6.4%.75fying that improved outcomes in the tPA treatment arm persist even when imbalances in the baseline stroke severity among treatment groups is corrected.70 Administration of IV tPA to patients with acute ischemic stroke who meet the NINDS eligibility criteria is recom￾mended if tPA is administered by physicians in the setting of a clearly defined protocol, a knowledgeable team, and insti￾tutional commitment (Class I). It is important to note that the superior outcomes reported in both community and tertiary care hospitals in the NINDS trials have been difficult to replicate in hospitals with less experience in, and institutional commitment to, acute stroke care.71,72 There is strong evi￾dence to avoid all delays and treat patients as soon as possible. Failure to adhere to protocol is associated with an increased rate of complications, particularly the risk of symptomatic intracranial hemorrhage.71,73 Community hospitals have reported outcomes comparable to the results of the NINDS trials after implementing a stroke program with a focus on quality improvement.61,74,75 The experience of the Cleveland Clinic system is instructive.71,75 A quality improvement program increased compliance with the tPA treatment protocol in 9 community hospitals, and the rate of symptomatic intracerebral hemorrhage fell from 13.4% to 6.4%.75 TABLE 3. Fibrinolytic Checklist Use of tPA in Patients With Acute Ischemic Stroke All boxes must be checked before tPA can be given. Note: The following checklist includes FDA-approved indications and contraindications for tPA administration for acute ischemic stroke. A physician with expertise in acute stroke care may modify this list. Inclusion Criteria (all Yes boxes in this section must be checked): Yes Age 18 years or older? Clinical diagnosis of ischemic stroke with a measurable neurologic deficit? Time of symptom onset (when patient was last seen normal) well established as
180 minutes (3 hours) before treatment would begin? Exclusion Criteria (all No boxes in “Contraindications” section must be checked): Contraindications: No Evidence of intracranial hemorrhage on pretreatment noncontrast head CT? Clinical presentation suggestive of subarachnoid hemorrhage even with normal CT? CT shows multilobar infarction (hypodensity greater than one third cerebral hemisphere)? History of intracranial hemorrhage? Uncontrolled hypertension: At the time treatment should begin, systolic pressure remains 185 mm Hg or diastolic pressure remains 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 but not limited to —Platelet count
100 000/mm3 ? —Heparin received within 48 hours, resulting in an activated partial thromboplastin time (aPTT) that is greater than upper limit of normal for laboratory? —Current use of anticoagulant (eg, warfarin sodium) that has produced an elevated international normalized ratio (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? Relative Contraindications/Precautions: Recent experience suggests that under some circumstances—with careful consideration and weighing of risk-to-benefit ratio—patients may receive fibrinolytic therapy despite one or more relative contraindications. Consider the pros and cons of tPA administration carefully if any of these relative contraindications is present: ● Only minor or rapidly improving stroke symptoms (clearing spontaneously) ● Within 14 days of major surgery or serious trauma ● Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days) ● Recent acute myocardial infarction (within previous 3 months) ● Postmyocardial 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 laboratory standards. IV-116 Circulation December 13, 2005