Time since last known well
0:00:00
Within 3 h window
≈ 154.3 lb
tPA / TNK eligibility
Incomplete — confirm all inclusion criteria below
Alteplase (tPA)
0.9 mg/kg · max 90 mg
Total
63 mg
63 mL
10% bolus / 1 min
6 mg
6 mL IV push
Infusion / 60 min
57 mg
57 mL @ 57 mL/h
Preparation
- Reconstitute 100 mg vial with 100 mL sterile water → 1 mg/mL. Swirl, do not shake.
- Withdraw and discard 37 mL from the vial so 63 mL (63 mg) remains.
- Draw 6 mL into a syringe → IV push over 1 min.
- Hang the remaining 57 mL on a pump at 57 mL/h × 60 min.
- Flush IV with 20 mL NS at the end. No heparin/antiplatelets × 24 h.
Total rounded to nearest 1 mg (1 mg/mL).
Tenecteplase (TNK)
0.25 mg/kg · max 25 mg
Single IV bolus over 5 sec
17.5 mg
= 3.5 mL of 5 mg/mL solution
Preparation
- Reconstitute 50 mg vial with 10 mL sterile water (or 25 mg vial with 5 mL) → 5 mg/mL. Swirl, do not shake.
- Draw 3.5 mL (17.5 mg) into a syringe.
- Administer as a single IV bolus over ~5 sec through a dedicated line.
- Flush with 10 mL NS at the same rate to clear the line.
- No heparin/antiplatelets × 24 h. Repeat NIHSS at 15 min, 1 h, 24 h.
Dose rounded to nearest 0.5 mg (5 mg/mL → 0.1 mL precision).
NIHSS — quick score
0
1a. LOC (alert/drowsy/stupor/coma)
1b. LOC questions (month, age)
1c. LOC commands (eyes, hand)
2. Best gaze
3. Visual fields
4. Facial palsy
5a. Motor — left arm
5b. Motor — right arm
6a. Motor — left leg
6b. Motor — right leg
7. Limb ataxia
8. Sensory
9. Best language
10. Dysarthria
11. Extinction / inattention
Inclusion — confirm all
0/4
Absolute exclusions — none should apply
0 triggered
Late window 3–4.5 h
Time from last-known-well. IV lytic still offered 3–4.5 h, but ECASS III adds extra exclusions below — any one blocks tPA/TNK in this window. Beyond 4.5 h: IV lytic not standard → consider EVT.
Acute ischemic stroke: LKW timer, NIHSS, weight-based lytics, BP targets, EVT pathway.
Management
BP targets
- Pre-lytic / candidate: < 185/110
- Post-lytic × 24 h: < 180/105
- Not for lytics (ischemic): permissive to ≤ 220/120
- Hemorrhagic stroke: SBP target 140–160
Thrombectomy (EVT)
NIHSS < 6 — EVT generally not indicated unless disabling deficit
- Get CTA head & neck (with IV contrast) to confirm LVO (ICA, M1, basilar)
- IV lytic and EVT are not mutually exclusive — give lytic if eligible while activating EVT
MRI indication
- Wake-up / unknown-LKW stroke: MRI brain without contrast (DWI / FLAIR mismatch — WAKE-UP trial) to qualify for IV lytic when LKW unknown.
- Posterior-circulation / brainstem signs with negative CT: MRI brain without contrast (DWI) — CT misses ~80% of acute brainstem infarcts.
- Diagnostic uncertainty / TIA work-up: MRI brain without contrast (DWI) within 24 h.
- Add contrast only if tumor, abscess, or vasculitis is suspected (MRI brain with & without contrast).
Stroke lab order set
Do not delay IV lytic for results except fingerstick glucose.
- Fingerstick glucoseSTAT — required pre-lyticExclude mimic; treat if < 50 or > 400 mg/dL
- CBC with plateletsPlatelets ≥ 100,000/µL< 100k = absolute lytic exclusion
- PT / INRINR ≤ 1.7Warfarin INR > 1.7 = exclusion
- aPTTWithin normal rangeElevated = exclusion if heparin exposure
- BMP (Na, K, BUN, Cr, glucose)Cr for contrast — do NOT delay lyticBaseline for CTA / EVT contrast
- Troponin + 12-lead ECGPer institution cutoffConcurrent ACS, AFib screening
- Type & Screen—In case of hemorrhagic conversion / EVT
- βhCG (women 12–55 y)NegativeDoes not delay lytic
- Anti-Xa level (apixaban, rivaroxaban, edoxaban, LMWH)< 0.5 IU/mL (institution-dependent)Send if DOAC / LMWH within 48 h
- Dilute thrombin time or ecarin clotting time (dabigatran)NormalSend if dabigatran within 48 h; idarucizumab if positive
- Lipid panel + HbA1c (admission)—Secondary prevention work-up
Suspect hemorrhagic stroke?
Open ICH pathway →
BP targets, anticoag/antiplatelet reversal, imaging, key dosing, and disposition.
Educational aid only — verify against local stroke protocol & most recent AHA/ASA guideline.