Stroke: thrombolysis checklist

Absolute: CT with extensive hypodensity; CT with hemorrhage; moderate–severe TBI <14 days; neurosurgery <14 days; acute spinal cord injury within 3 months; intra-axial neoplasm; infective endocarditis; severe coagulopathy or thrombocytopenia (platelets <100 000/mm³, INR >1.7, aPTT >40 s, PT >15 s); aortic arch dissection; amyloid immunotherapy or ARIA.

Relative — individualize: pre-existing disability; DOAC exposure <48 h; ischemic stroke within 3 months; prior ICH; major non-CNS trauma 14 days–3 months; major non-CNS surgery within 10 days; GI/GU bleeding within 21 days; intracranial arterial dissection; intracranial vascular malformation; STEMI within 3 months; acute pericarditis; LA/LV thrombus; systemic active malignancy; pregnancy and postpartum; dural puncture within 7 days; noncompressible arterial puncture within 7 days; moderate–severe TBI or neurosurgery 14 days–3 months.

Benefit generally greater than bleeding risk: extracranial cervical dissection; extra-axial intracranial neoplasm; angiographic procedural stroke; unruptured intracranial aneurysm; remote stable GI/GU bleeding; remote MI; recreational drug use; uncertainty about stroke vs mimic; Moya-Moya.

Label differences: both US labels still list recent intracranial/intraspinal surgery or serious head trauma (Activase 3 months, TNKase 2 months), intracranial conditions such as AVMs or aneurysms, bleeding diathesis, active internal bleeding and (Activase) subarachnoid hemorrhage as contraindications. Where 2026 says “individualize”, use outside the label rests on the guideline.

DOAC <48 h (2026): safety unknown; may be considered after an individual benefit–risk analysis — timing of the last dose, renal function, stroke severity, EVT availability, reversal agents and drug-specific anti-Xa/thrombin-time assays. Full-dose LMWH within 24 h is not in the 2026 table; the 2019 table said not to give IVT (COR 3: Harm).

• ≤4.5 h from last known well: tenecteplase or alteplase (2026 COR 1). Both US labels say “within 3 hours”; 3–4.5 h use is guideline-based.
• Unknown onset, MRI-selected (COR 2a): within 4.5 h of symptom recognition, DWI lesion smaller than one-third of the MCA territory and no marked FLAIR change (WAKE-UP).
• Perfusion-selected (COR 2a): salvageable penumbra on automated perfusion imaging and either awoke with symptoms within 9 h of the midpoint of sleep, or 4.5–9 h from last known well.
• 4.5–24 h, LVO (COR 2b): salvageable penumbra and thrombectomy not possible, directed by clinicians with thrombolysis expertise.
• Non-disabling deficits (e.g. isolated sensory) within 4.5 h: IVT not recommended — dual antiplatelet therapy preferred.

Table 7 footnote: if <50 kg and an accurate weight is known, dosing per 1-kg band may be used; do not delay thrombolysis to obtain an exact weight; with estimated weights, 1-kg banding is not necessarily safer. The tool applies 0.25 mg/kg × weight to the nearest kg only when “weight measured” is ticked. Weight is rounded to 0.1 kg before banding so the band matches the number shown.

TNK: single IV bolus over 5 s; flush dextrose lines with saline. The STEMI table is double (30–50 mg) — use the stroke table.

sICH within 24 h: stop alteplase (or TNK if still being pushed); CBC, PT/INR, aPTT, fibrinogen, type and cross-match; emergent noncontrast CT; cryoprecipitate 10 U over 10–30 min to keep fibrinogen ≥150 mg/dL; tranexamic acid 1000 mg IV over 10 min or ε-aminocaproic acid 4–5 g over 1 h then 1 g/h until controlled; hematology and neurosurgery; supportive BP, ICP, CPP, temperature and glucose care.

Orolingual angioedema (more likely with ACE inhibitors): maintain airway (anterior tongue/lips only may not need intubation; larynx, palate, floor of mouth or oropharynx with progression within 30 min is higher risk; awake fiberoptic preferred); stop alteplase and hold ACE inhibitors; methylprednisolone 125 mg IV, diphenhydramine 50 mg IV, famotidine 20 mg IV; epinephrine 0.3 mL of 1 mg/mL SC or nebulized if it progresses; icatibant 30 mg SC or C1-esterase inhibitor 20 IU/kg as options.

• Check glucose before treatment. Without a reason to suspect abnormal results, do not wait for platelets or coagulation tests (2026 COR 2a); with recent warfarin or heparin, wait for them.
• Weigh the patient when possible, but do not delay treatment for an exact weight.
• Do not give IV aspirin within 90 min of alteplase; hold antithrombotics until the 24-h scan.
• Do not skip lytic therapy to speed thrombectomy, and do not wait to see a response before EVT.