Alteplase Administration for Acute Ischemic Stroke

Dosing Protocol

The American Heart Association recommends administering alteplase at 0.9 mg/kg (maximum 90 mg total) with 10% given as an IV bolus over 1 minute and the remaining 90% as an IV infusion over 60 minutes 1, 2, 3
The total dose is calculated as 0.9 mg/kg body weight, with a maximum of 90 mg 1, 2, 3
The initial bolus is 10% of the total dose, administered as 0.09 mg/kg IV push over exactly 1 minute 1, 2, 3
The infusion is 90% of the total dose, administered as 0.81 mg/kg IV infusion over 60 minutes 1, 2, 3

The American Stroke Association recommends a door-to-needle time of <60 minutes in 90% of patients, with an optimal median of 30 minutes 1, 2, 3
Alteplase should be initiated immediately after CT scan confirms no hemorrhage 1, 2, 3

The European Stroke Organisation recommends consulting radiology immediately if there is uncertainty about CT interpretation 2, 4
The American Heart Association recommends assessing for extensive early infarct changes using the ASPECTS score 5, 4

The American College of Cardiology recommends not routinely administering alteplase to patients on DOACs, except in comprehensive stroke centers with DOAC level testing and reversal agents available 2, 3, 4

The American Heart Association recommends holding all antiplatelet agents for 24 hours post-alteplase 1, 2, 3
The European Stroke Organisation recommends a staged response to angioedema, including antihistamines, glucocorticoids, and standard airway management per protocol 2

The American Stroke Association recommends urgently consulting a stroke specialist via telestroke or in-person when eligibility is unclear 2, 4
The American College of Cardiology recommends same rapid evaluation and treatment access for inpatients developing acute stroke symptoms as for ED patients 1, 2, 3

The American Heart Association recommends avoiding the use of MI dosing protocol for stroke, as it is incorrect and potentially harmful 1, 2, 3
The European Stroke Organisation recommends treating based on non-contrast CT alone when within window, rather than delaying for a "perfect" workup 1, 2, 3
The American College of Cardiology recommends avoiding administration of alteplase to DOAC patients without specialized testing 2, 3, 4

The American Heart Association recommends IV alteplase (0.9 mg/kg, maximum dose 90 mg) for selected patients with acute ischemic stroke within 3 hours of symptom onset 6, 7
Treatment can be extended to 3-4.5 hours in selected patients ≤80 years of age without a history of both diabetes mellitus and prior stroke, with NIHSS score ≤25, not taking oral anticoagulants, and without imaging evidence of ischemic injury involving more than one-third of the MCA territory 6, 7
Treatment should be initiated as quickly as possible as time to treatment is strongly associated with outcomes 7

The American Heart Association recommends against alteplase administration in patients with evidence of intracranial hemorrhage on CT 6, 8
Severe head trauma within 3 months is a contraindication for alteplase administration 6, 8
Ischemic stroke within 3 months is a contraindication for alteplase administration 6, 8
History of intracranial hemorrhage is a contraindication for alteplase administration 8, 9
Coagulopathy (platelets <100,000/mm³, INR >1.7, aPTT >40 s, or PT >15 s) is a contraindication for alteplase administration 8, 9
Treatment with low molecular weight heparin within the previous 24 hours is a contraindication for alteplase administration 8, 9
Active internal bleeding or recent (within 21 days) gastrointestinal or urinary tract hemorrhage is a contraindication for alteplase administration 8, 10

Blood pressure should be lowered safely to <185/110 mm Hg before starting IV alteplase 7
In patients treated with alteplase for stroke, initiation of antiplatelet agents should be delayed until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage 11

There are no established guidelines for systemic co-administration of alteplase and dornase alpha 9