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Stroke (Acute Ischemic Stroke – IV tPA – Adult)

Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department (2012)

Complete Clinical Policy on IV tPA for Acute Ischemic Stroke (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based emergency departments.

Inclusion Criteria. This guideline is intended for adult patients presenting to the ED with acute ischemic stroke.

Exclusion Criteria. This guideline is not intended to be applied to children younger than 18 years.

Critical Questions

Is IV tPA safe and effective for acute ischemic stroke patients if given within 3 hours of symptom onset?

Is IV tPA safe and effective for acute ischemic stroke patients treated between 3 to 4.5 hours after symptom onset?


  • Level A recommendations. In order to improve functional outcomes, IV tPA should be offered to acute ischemic stroke patients who meet National Institute of Neurological Disorders and Stroke (NINDS) inclusion/exclusion criteria and can be treated within 3 hours after symptom onset.*
      
  • Level B recommendations. In order to improve functional outcomes, IV tPA should be considered in acute ischemic stroke patients who meet European Cooperative Acute Stroke Study (ECASS) III inclusion/exclusion criteria and can be treated between 3 to 4.5 hours after symptom onset.*

    *The effectiveness of tPA has been less well established in institutions without the systems in place to safely administer the medication.
    Note: Within any time window, once the decision is made to administer IV tPA, the patient should be treated as rapidly as possible. As of this writing, tPA for acute ischemic stroke in the 3- to 4.5-hour window is not FDA approved.
      
  • Level C recommendations. None specified.

Purpose of ACEP’s Clinical Policies

Clinical Findings and Strength of Recommendations