Intravenous Alteplase for Acute Ischemic Stroke Within 4.5 Hours
IV alteplase is indicated for patients with acute ischemic stroke who can be treated within 4.5 hours of symptom onset and meet established eligibility criteria [1][2].
Treatment is contraindicated in the presence of absolute exclusion factors such as intracranial hemorrhage or recent intracranial surgery [1][2].
Relative contraindications and additional exclusion criteria modify eligibility and require clinical judgment [3][4].
Indications
- Acute ischemic stroke confirmed by clinical assessment and neuroimaging.
- Treatment can be initiated ≤ 4.5 hours from last known well.
- No evidence of intracranial hemorrhage on non‑contrast CT or MRI.
- Baseline NIHSS score typically ≥ 4 (mild non‑disabling deficits often excluded) [4].
Absolute Contraindications
- Intracranial hemorrhage on initial imaging.
- Prior intracranial or intraspinal surgery, or serious head trauma, within 3 months.
- History of intracranial neoplasm, arteriovenous malformation, or aneurysm rupture.
- Uncontrolled hypertension > 185/110 mm Hg at presentation despite urgent treatment.
- Active internal bleeding or known bleeding diathesis (platelets < 100 × 10⁹/L, INR > 1.7, PT > 15 seconds).
- Recent (≤ 3 months) use of direct oral anticoagulants with elevated labs, or warfarin with INR > 1.7.
Relative Contraindications
- Recent major surgery or trauma (within 14 days).
- Recent gastrointestinal or urinary tract hemorrhage (within 21 days).
- Minor or rapidly improving stroke symptoms (NIHSS ≤ 5) where risk may outweigh benefit [4].
- History of intracranial hemorrhage more than 3 months ago.
- Pregnancy.
- Severe hyperglycemia (> 400 mg/dL) or hypoglycemia (< 50 mg/dL) at presentation.
- Recent ischemic stroke or myocardial infarction within 3 months.
Key Exclusion Criteria (Guideline‑Based)
- Presence of a large established infarct core on imaging (e.g., hypodensity > 1/3 MCA territory).
- Evidence of subarachnoid hemorrhage or other non‑ischemic bleed on imaging.
- Current use of anticoagulant therapy with elevated coagulation parameters as noted above.
- Uncontrolled systolic blood pressure > 185 mm Hg or diastolic > 110 mm Hg despite rapid antihypertensive therapy.
- Known diagnosis of diabetic retinopathy is not an absolute contraindication and does not exclude treatment [3].
Special Populations
- Cervical artery dissection patients may receive IV alteplase; data do not define it as a contraindication [5].
- Patients on heparin should have the infusion withheld for ≥ 24 hours after alteplase unless urgent anticoagulation is required [6].