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. 2016 Nov-Dec;113(6):480–486.

Table 3.

Checklist for Inclusion and Exclusion Criteria for Thrombolytic Therapy

STROKE TEAM – RAPID EVALUATION
1. TIME PATIENT LAST KNOWN WELL: ___________________
2. TIME OF PATIENT ARRIVAL TO FACILITY: ___________________
Pre-Admission Blood Thinners & Plaque Stabilizers:
  Antiplatelet therapy: Aspirin [ ] Plavix [ ]
  Anticoagulation: Coumadin [ ] Lovenox [ ] Other: _________
  Statin: Yes [ ] No [ ] Which: ________
Cerebral Vascular Risk Factors:
  Hypertension Yes [ ] No [ ]
  Hyperlipidemia Yes [ ] No [ ]
  Smoking Yes [ ] No [ ]
  Atrial Fibrillation Yes [ ] No [ ]
  Age >60 years Yes [ ] No [ ]
  Diabetes Yes [ ] No [ ]
Exclusion Criteria for Tissue Plasminogen Activator (tPA)
  1. Evidence of an acute intracranial hemorrhage Yes [ ] No [ ]
  2. Major Early CT signs of infarction Yes [ ] No [ ]
  3. Another stroke, serious head trauma, intracranial surgery in the past 3 months Yes [ ] No [ ]
  4. Intracranial neoplasm, AVM, or an aneurysm Yes [ ] No [ ]
  5. Uncontrolled hypertension (systolic >185, diastolic >110) Yes [ ] No [ ]
  6. Rapidly improving or minor symptoms Yes [ ] No [ ]
  7. Symptoms suggesting subarachnoid hemorrhage Yes [ ] No [ ]
  8. History of intracranial bleed Yes [ ] No [ ]
  9. Major surgery in the past 14 days Yes [ ] No [ ]
  10. Known bleeding disorder Yes [ ] No [ ]
  11. GI or GU bleed in the past 3 weeks Yes [ ] No [ ]
  12. Arterial puncture at a non-compressible site in the past 7 days Yes [ ] No [ ]
  13. Seizure at the onset of stroke Yes [ ] No [ ]
  14. Pt >15, INR >1.7 Yes [ ] No [ ]
  15. Heparin within the past 48 hours and elevated aPTT Yes [ ] No [ ]
  16. Use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and ECT; TT or appropriate factor Xa activity assays) Yes [ ] No [ ]
  17. Platelet count <100,000 Yes [ ] No [ ]
  18. Serum Glucose <50mg/dL or >400mg/dL Yes [ ] No [ ]
  19. MI in the past 3 months Yes [ ] No [ ]
Exclusion Criteria of IV tPA within 3 to 4.5 hours
  1. Age >80 years Yes [ ] No [ ]
  2. Severe stroke (NIHSS>25) Yes [ ] No [ ]
  3. Taking an oral anticoagulant regardless of INR Yes [ ] No [ ]
  4. History of both diabetes and prior ischemic stroke Yes [ ] No [ ]