What are the AHA/ASA inclusion guidelines for fibrinolytic therapy 3-4.5 hours after symptom onset in ischemic stroke?

Updated: May 27, 2020
  • Author: Edward C Jauch, MD, MS, FAHA, FACEP; Chief Editor: Helmi L Lutsep, MD  more...
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An rt-PA stroke study group from the National Institute of Neurologic Disorders and Stroke (NINDS) first reported that the early administration of rt-PA benefited carefully selected patients with acute ischemic stroke. [3] The FDA subsequently approved the use of rt-PA in patients who met NINDS criteria. In particular, rt-PA had to be given within 3 hours of stroke onset and only after CT scanning had ruled out hemorrhagic stroke.

Subsequently, fibrinolytic therapy administered 3–4.5 hours after symptom onset was found to improve neurologic outcomes in the European Cooperative Acute Stroke Study III (ECASS III), suggesting a wider time window for fibrinolysis in carefully selected patients. [83] On the basis of these and other data, in May 2009 the AHA/ASA revised the guidelines for the administration of rt-PA after acute stroke, expanding the window of treatment from 3 hours to 4.5 hours to provide more patients with an opportunity to benefit from this therapy. [83, 84, 85, 86]

Eligibility criteria for treatment during this later period are similar to those for earlier treatment but are more stringent, with any 1 of the following serving as an additional exclusion criterion:

  • Age older than 80 years

  • Use of oral anticoagulants, regardless of the INR

  • Baseline score on the National Institutes of Health Stroke Scale (NIHSS) greater than 25

  • History of stroke and diabetes

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