CHECKLIST: tPA Eligibility Criteria

From ENLS / ACC/AHA 2013


Diagnosis of ischemic stroke causing measurable neurological deficit. Neurological signs should not be minor and isolated. Neurological

signs should not be clearing spontaneously

Onset less than 3 h before initiating alteplase

Patient is at least 18 years old (see section on special considerations: pediatric stroke)

Absolute exclusion criteria if positive

No major head trauma or prior stroke in the previous 3 months

Symptoms of stroke should not be suggestive of subarachnoid hemorrhage

No arterial puncture at a non-compressible site or lumbar puncture in the previous 7 days

No history of previous intracranial hemorrhage

No history of intracranial neoplasm, aneurysm, or arteriovenous malformation

No intracranial or intraspinal surgery in the previous 3 months

Blood pressure not elevated (systolic <185 mmHg and diastolic <110 mmHg)

No evidence of active bleeding or acute trauma (fracture) on examination

Platelet count <100,000 mm


If receiving heparin in previous 48 h, aPTT must be in normal range

Not taking an oral anticoagulant or, if anticoagulant being taken, INR < 1.7 or PT > 15 s

No dabigatran, apixaban, or rivaroxaban use for chronic anticoagulation for conditions such as atrial fibrillation. There is still little

information on assessing influence or levels of these medications in patients with acute stroke. There are suggestions to check an activated

thromboplastin time (aPTT), INR, platelet count, thromboplastin time (TT), ecarin clotting time (ECT) and anti factor 10a level (if

available). Without normalized special tests (as listed), use of alteplase is NOT recommended in patients with recent use (within 48 h) of

these products

Blood glucose concentration <50 mg/dL (2.7 mmol/L)

CT does not show a multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Relative exclusion criteria if positive—use caution if recommending alteplase if one or more are positive

Stroke symptoms are rapidly improving or only minor


Seizure with postictal residual neurological impairments

Major surgery or major trauma in the previous 14 days

Gastrointestinal or urinary tract hemorrhage in the previous 21 days

Myocardial infarction in the previous 3 months

Some additional considerations

Caution should be exercised in treating a patient with major deficits

Caution using alteplase in patients treated with low molecular weight heparin in the past 24 h

Patient or family members understand the potential risks and benefits from treatment. No written consent is required but the conversation

should be documented in the clinical notes. Do not delay IV therapy if a surrogate is not readily available as this can lead to worse outcomes

Alteplase is not FDA approved for treatment of patients under the age of 18. However, alteplase has been used off-label in selected pediatric

patients with strokes, following careful counseling of parents and using identical eligibility and contraindication criteria to those used in



Inclusion criteria

  • Clinical diagnosis of ischemic stroke causing measurable neurologic deficit
  • Onset of symptoms <4.5 hours before beginning treatment; if the exact time of
  • stroke onset is not known, it is defined as the last time the patient was known to be normal
  • Age ≥18 years

Exclusion criteria

  • Historical
    • Significant stroke or head trauma in the previous three months
    • Previous intracranial hemorrhage
    • Intracranial neoplasm, arteriovenous malformation, or aneurysm
    • Recent intracranial or intraspinal surgery
    • Arterial puncture at a noncompressible site in the previous seven days
  • Clinical
    • Symptoms suggestive of subarachnoid hemorrhage
    • Persistent blood pressure elevation (systolic ≥185 mmHg or diastolic ≥110 mmHg)
    • Serum glucose <50 mg/dL (<2.8 mmol/L)
    • Active internal bleeding
    • Acute bleeding diathesis, including but not limited to conditions defined in ‘Hematologic’
  • Hematologic
    • Platelet count <100,000/mm3*
    • Current anticoagulant use with an INR >1.7 or PT >15 seconds*
    • Heparin use within 48 hours and an abnormally elevated aPTT*
    • Current use of a direct thrombin inhibitor or direct factor Xa inhibitor with evidence of anticoagulant effect by laboratory tests such as aPTT, INR, ECT, TT, or appropriate factor Xa activity assays
  • Head CT scan
    • Evidence of hemorrhage
    • Extensive regions of obvious hypodensity consistent with irreversible injury
  • Relative exclusion criteria¶
    • Only minor and isolated neurologic signs
    • Rapidly improving stroke symptoms
    • Major surgery or serious trauma in the previous 14 days
    • Gastrointestinal or urinary tract bleeding in the previous 21 days
    • Myocardial infarction in the previous three months
    • Seizure at the onset of stroke with postictal neurologic impairments
    • Pregnancy
  • Additional relative exclusion criteria for treatment from 3 to 4.5 hours from symptom onset
    • Age >80 years
    • Oral anticoagulant use regardless of INR
    • Severe stroke (NIHSS score >25)
    • Combination of both previous ischemic stroke and diabetes mellitus

<Eligibility criteria for tPA in PDF format>



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