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Up until recently, it was recommended that stroke patients only receive the thrombolytic alteplase until 4.5 hrs after last known well. After this time, there was no evidence supporting intravenous thrombolytic to improve patient outcomes.
Various studies over the past few years (e.g., WAKE-UP Trial) have opened the window of patient eligibility for IV thrombolytic to 9 hrs from last known well and even allows those with a wake-up stroke (unknown time of onset) to be eligible for this treatment option if deemed appropriate after MRI. This practice is now a Class IIa recommendation from AHA in the most recent Stroke Guidelines.
Go-Live Date: Monday, 11/15/2021
Eligibility Requirements
Clinical syndrome consistent with acute ischemic stroke
Meets One of the Following Criteria:
Wake-Up Stroke or unclear time of onset for patients who arrive within 4.5 hours of stroke recognition
Time stroke symptoms first noted: 4.5 – 9 hrs
Measurable disabling neurologic deficit = Impairment of 1 or more of the following (WAKE UP Trial):
Language
Motor Function
Cognition
Gaze
Vision
Neglect
Age:18 – 80 YO
Baseline Functional Status: Patient requires no or minimal assistance
CT negative for established infarct and hemorrhage
CTA head / neck negative for large vessel occlusion (not a candidate for mechanical thrombectomy)
CTP does not show large, established infarct
No contraindications to IV alteplase
NIHSS < 25
< 1/3 MCA territory
**FLAIR Lesion = stroke > 4.5 hrs
**Negative DWI = Stroke Mimic
Workflow
Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
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