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may be more likely to result in a favorable outcome. Later treatment, at 90 to 180 minutes, also is beneficial. Patients with major strokes (NIHSS score >22) have a very poor prognosis, but some positive treatment effect with rtPA has been documented.329 Because the risk of hemorrhage is considerable among patients with severe deficits, the decision to treat with rtPA should be made with caution. Treatment with rtPA is associated with symptomatic intracranial hemorrhage, which may be fatal. In the original NINDS trials, the risk of symptomatic bleeding was ≈6%.100 Recent community-based studies and registries report lower rates of hemorrhage.269,330–333 Recommendations for the management of intracranial hemorrhage after treatment with rtPA are provided in the AHA Stroke Council’s updated guideline statement on management of intracerebral hemorrhage, which is being issued contemporaneously with this statement. The best methods for preventing bleeding complications are careful selection of patients and scrupulous ancillary care, especially close observation, and monitoring of the patient with early treatment of arterial hypertension. Factors that affect decisions about administration of rtPA are outlined in , and the treatment regimen for administration of rtPA is included in Case series have suggested that thrombolysis may be used in patients with seizures at the time of presentation when evidence suggests that residual deficits are due to ischemia rather than the postictal state. The use of anticoagulants and antiplatelet agents should be delayed for 24 hours after treatment.TABLE 11. Characteristics of Patients With Ischemic Stroke Who Could Be Treated With rtPA Although written consent is not necessary before administration of rtPA for treatment of stroke, a full discussion of the potential risks and benefits of treatment with rtPA with the family and the patient if possible is recommended. Although other thrombolytic agents, including defibrinogenating drugs, are being tested, none has been established as effective or as a replacement for rtPA. Class I Recommendations 1. Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke (Class I, Level of Evidence A). Physicians should review the criteria outlined in Table 11 (which are modeled on those used in the NINDS trial) to determine the eligibility of the patient. A recommended regimen for observation and treatment of the patient is described in Table 12. This recommendation has not changed from previous statements. 2. Besides bleeding complications, physicians should be aware of the potential side effect of angioedema that may cause partial airway obstruction (Class I, Level of Evidence C). This recommendation has been added since the previous guidelines. Class II Recommendations 1. A patient whose blood pressure can be lowered safely with antihypertensive agents may be eligible for treatment, and the physician should assess the stability of the blood pressure before starting rtPA (Class IIa, Level of Evidence B). An elevated blood pressure that requires a continuous infusion of sodium nitroprusside may not be sufficiently stable for the patient to receive rtPA. However, because time is limited, most patients with markedly elevated blood pressure cannot be managed adequately and still meet the 3-hour requirement. This recommendation has not changed from previous guidelines. 2. A patient with a seizure at the time of onset of stroke may be eligible for treatment as long as the physician is convinced that residual impairments are secondary to stroke and not a postictal phenomenon (Class IIa, Level of Evidence C).