Thrombolysis for Acute Ischemic Stroke

Primary Treatment Recommendations

The American College of Chest Physicians strongly recommends IV recombinant tissue plasminogen activator (r-tPA) for acute ischemic stroke if treatment can be initiated within 3 hours of symptom onset, with a weaker recommendation for treatment between 3-4.5 hours after onset (Grade 1A evidence and Grade 2C evidence) 1, 2
IV r-tPA (0.9 mg/kg, maximum dose 90 mg) is the recommended first-line treatment for eligible patients with acute ischemic stroke 2

Early aspirin therapy (160-325 mg) is recommended within 48 hours of stroke onset (Grade 1A) 2
For patients with restricted mobility, prophylactic-dose subcutaneous heparin (preferably LMWH) or intermittent pneumatic compression devices are suggested (Grade 2B) 2
LMWH is preferred over unfractionated heparin (Grade 2B) 2
Elastic compression stockings are not recommended (Grade 2B) 2

Patient selection is crucial to minimize hemorrhagic complications, excluding patients with evidence of intracranial hemorrhage on imaging 2
Carefully assess for contraindications to thrombolysis 2
Consider risk factors for hemorrhagic transformation 2