tPA Administration Criteria Checklist
AHA/ASA Guideline-based Administration Eligibility Verification
tPA Administration Eligibility Check
Important Safety Notice
tPA is a medication with bleeding risk. Only administer if all inclusion criteria are met and no exclusion criteria are present.
Eligibility for tPA (tPA Inclusion Criteria)
Is the patient clinically diagnosed with acute ischemic stroke with disabling neurological deficit?
Must show symptoms of ischemic stroke with meaningful disabling neurological symptoms (including minor but disabling symptoms).
Is the onset within 4.5 hours?
Within 4.5 hours from last known normal time
Is the patient 18 years or older?
Adult patients (18 years or older)
Is blood pressure <185/110 mmHg or safely controllable with medication?
Systolic <185 and diastolic <110 controllable with antihypertensives
Is blood glucose ≥50mg/dL?
Confirm patient is not in hypoglycemic state
Absolute Contraindications to tPA
Is there intracranial hemorrhage on CT?
Any form of intracranial hemorrhage on CT is an absolute contraindication
Is there extensive clear hypodensity on CT?
Extensive clear hypodensity indicates irreversible damage with poor prognosis
Is there a history of intracranial hemorrhage?
Previous intracerebral hemorrhage
Are there symptoms suggestive of subarachnoid hemorrhage?
Acute severe headache, meningeal irritation signs, etc.
Was there an ischemic stroke within the past 3 months?
Ischemic stroke history within 3 months
Was there serious head trauma within the past 3 months?
Major head trauma history
Was there intracranial/spinal surgery within the past 3 months?
Brain surgery, spinal surgery history
Was there gastrointestinal bleeding or malignancy within the past 21 days?
Structural gastrointestinal malignancy or recent bleeding history
Are there coagulopathy findings: platelets <100,000/mm³, INR >1.7, aPTT >40sec, PT >15sec?
Presence of coagulation disorders
Was therapeutic dose low molecular weight heparin (LMWH) given within the past 24 hours?
Therapeutic dose LMWH such as Enoxaparin
Is the patient taking DOAC or Factor Xa inhibitors?
Dabigatran, Rivaroxaban, Apixaban, Edoxaban, etc. (May consider if related tests are normal or not taken for >48 hours with normal kidney function.)
Is the patient receiving glycoprotein IIb/IIIa receptor inhibitors?
abciximab, Eptifibatide, tirofiban, etc.
Is infective endocarditis suspected?
When symptoms of infective endocarditis are present
Is aortic arch dissection suspected or diagnosed?
Stroke related to aortic arch dissection
Is there an intra-axial intracranial neoplasm?
Intraparenchymal tumor
Relative Contraindications/Warnings to tPA
Note: These items are not absolute contraindications, but require careful risk-benefit assessment for tPA administration. Even with these conditions present, administration may be possible under neurologist judgment.
Was there a seizure at stroke onset?
Need to distinguish post-ictal symptoms from stroke symptoms
⚠️ Consideration Reasonable if residual impairment is clearly due to stroke (Class IIa)
Is blood glucose >400mg/dL?
Initial blood glucose >400mg/dL but normalized
⚠️ Consideration May be reasonable if glucose is normalized and other conditions are met (Class IIb)
Is the patient pregnant?
tPA use during pregnancy
⚠️ Consideration May be considered if expected benefit outweighs uterine bleeding risk in moderate-severe stroke (Class IIb)
Was there a myocardial infarction within the past 3 months?
Recent myocardial infarction history
⚠️ Consideration NSTEMI is reasonable (Class IIa), right/inferior STEMI is reasonable (Class IIa), anterior STEMI may be reasonable (Class IIb)
Was there major surgery within the past 14 days?
Major surgery within 14 days
⚠️ Consideration Compare surgical site bleeding risk with benefit of reducing stroke disability (Class IIb)
Was there major trauma (excluding head) within the past 14 days?
Major trauma excluding head within 14 days
⚠️ Consideration Carefully consider comparing trauma-related bleeding risk with stroke severity (Class IIb)
Was there arterial puncture at a non-compressible site within the past 7 days?
Arterial puncture at non-compressible vessel sites
⚠️ Consideration Safety and efficacy uncertain (Class IIb)
Was there lumbar puncture within the past 7 days?
Lumbar puncture within 7 days
⚠️ Consideration May be considered (Class IIb)
Are there >10 cerebral microbleeds (CMBs) on MRI?
Multiple cerebral microbleeds (>10) on MRI
⚠️ Consideration Possible increased bleeding risk; may be reasonable if substantial benefit expected (Class IIb)
Is there an unruptured cerebral aneurysm (≥10mm)?
Large unruptured cerebral aneurysm
⚠️ Consideration Usefulness and risk not well established (Class IIb)
Is there an unruptured intracranial vascular malformation (AVM, cavernous malformation, etc.)?
Unruptured intracranial vascular malformations
⚠️ Consideration Usefulness and risk not well established. May be considered if severe neurological deficit and expected morbidity/mortality risk outweighs hemorrhage risk (Class IIb)
Is there current malignancy?
Systemic malignancy
⚠️ Consideration Potential benefit if >6 months life expectancy and no other contraindications (Class IIb)
Additional Warnings to tPA >3hr Onset
In the 3-4.5 hour window, is the patient >80 years old?
Elderly patients in the 3-4.5 hour window
⚠️ Consideration Patients >80 years may be safe and effective in the 3-4.5 hour window (Class IIa)
In the 3-4.5 hour window, is the patient taking warfarin with INR ≤1.7?
Taking warfarin but INR ≤1.7 in the 3-4.5 hour window
⚠️ Consideration May be safe and beneficial (Class IIb)
In the 3-4.5 hour window, does the patient have both diabetes and prior stroke history?
Diabetes and previous stroke history in the 3-4.5 hour window
⚠️ Consideration May be as effective as 0-3 hour window and may be a reasonable choice (Class IIb)
In the 3-4.5 hour window, is the NIHSS score >25?
Very severe stroke in the 3-4.5 hour window
⚠️ Consideration Benefit uncertain in the 3-4.5 hour window (Class IIb)
In the 3-4.5 hour window, are there ischemic changes in >1/3 of MCA territory on CT?
Extensive early ischemic changes in the 3-4.5 hour window
⚠️ Consideration Contraindicated in 3-4.5 hour window if >1/3 MCA ischemic changes present
Reference
Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e158-e308. doi:10.1161/STR.0000000000000158