title: Pennsylvania comprehensive stroke center collaborative: Statement on the recently updated IV rt-PA prescriber information for acute ischemic stroke.
abstract: OBJECTIVE
  Recently, the FDA guidelines regarding the eligibility of patients with acute ischemic stroke to receive IV rt-PA have been modified and are not in complete accord with the latest AHA/ASA guidelines. The resultant differences may result in discrepancies in patient selection for intravenous thrombolysis.
  
  
  METHODS
  Several comprehensive stroke centers in the state of Pennsylvania have undertaken a collaborative effort to clarify and unify our own recommendations regarding how to reconcile these different guidelines.
  
  
  RESULTS
  Seizure at onset of stroke, small previous strokes that are subacute or chronic, multilobar infarct involving more than one third of the middle cerebral artery territory on CT scan, hypoglycemia, minor or rapidly improving symptoms should not be considered as contraindications for intravenous thrombolysis. It is recommended to follow the AHA/ASA guidelines regarding blood pressure management and bleeding diathesis. Patients receiving factor Xa inhibitors and direct thrombin inhibitors within the preceding 48 h should be excluded from receiving IV rt-PA. CT angiography is effective in identifying candidates for endovascular therapy. Consultation with and/or transfer to a comprehensive stroke center should be an option where indicated. Patients should receive IV rt-PA up to 4.5h after the onset of stroke.
  
  
  CONCLUSIONS
  The process of identifying patients who will benefit the most from IV rt-PA is still evolving. Considering the rapidity with which patients need to be evaluated and treated, it remains imperative that systems of care adopt protocols to quickly gather the necessary data and have access to expert consultation as necessary to facilitate best practices.
authors.affiliation: Thomas Jefferson University Hospital, Department of Neurosurgery, Philadelphia, PA, United States.
authors.forename: Badih
authors.initials: B
authors.lastname: Daou
authors.affiliation: Thomas Jefferson University Hospital, Department of Neurosciences Institute, Philadelphia, PA, United States.
authors.forename: Maureen
authors.initials: M
authors.lastname: Deprince
authors.affiliation: Thomas Jefferson University Hospital, Department of Neurosciences Institute, Philadelphia, PA, United States.
authors.forename: Robin
authors.initials: R
authors.lastname: D'Ambrosio
authors.affiliation: Thomas Jefferson University Hospital, Department of Neurosurgery, Philadelphia, PA, United States.
authors.forename: Stavropoula
authors.initials: S
authors.lastname: Tjoumakaris
authors.affiliation: Thomas Jefferson University Hospital, Department of Neurosurgery, Philadelphia, PA, United States.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Rosenwasser
authors.affiliation: Thomas Jefferson University Hospital, Department of Neurology, Philadelphia, PA, United States.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Ackerman
authors.affiliation: Thomas Jefferson University Hospital, Department of Neurology, Philadelphia, PA, United States.
authors.forename: Rodney
authors.initials: R
authors.lastname: Bell
authors.affiliation: Thomas Jefferson University Hospital, Department of Neurology, Philadelphia, PA, United States.
authors.forename: Diana L
authors.initials: DL
authors.lastname: Tzeng
authors.affiliation: Thomas Jefferson University Hospital, Department of Neurology, Philadelphia, PA, United States.
authors.forename: Michelle
authors.initials: M
authors.lastname: Ghobrial
authors.affiliation: Thomas Jefferson University Hospital, Department of Neurology, Philadelphia, PA, United States.
authors.forename: Andres
authors.initials: A
authors.lastname: Fernandez
authors.affiliation: Abington Memorial Hospital, Division of Neurointervention and Neuocritical Care, Abington, PA, United States.
authors.forename: Qaisar
authors.initials: Q
authors.lastname: Shah
authors.affiliation: Diamond Stroke Center, Abington, PA, United States.
authors.forename: Dan J
authors.initials: DJ
authors.lastname: Gzesh
authors.affiliation: Abington Memorial Hospital, Division of Neurointervention and Neuocritical Care, Abington, PA, United States.
authors.forename: Deborah
authors.initials: D
authors.lastname: Murphy
authors.affiliation: Lehigh Valley Health Network Division of Neurology, Allentown, PA, United States.
authors.forename: John E
authors.initials: JE
authors.lastname: Castaldo
authors.affiliation: Lehigh Valley Health Network Division of Neurology, Allentown, PA, United States.
authors.forename: Claranne
authors.initials: C
authors.lastname: Mathiesen
authors.affiliation: Thomas Jefferson University Hospital, Department of Neurology, Philadelphia, PA, United States.
authors.forename: Maria Carissa
authors.initials: MC
authors.lastname: Pineda
authors.affiliation: Thomas Jefferson University Hospital, Department of Neurosurgery, Philadelphia, PA, United States. Electronic address: pascal.jabbour@jefferson.edu.
authors.forename: Pascal
authors.initials: P
authors.lastname: Jabbour
mesh_terms: D061605:Administration, Intravenous; D000991:Antithrombins / Q000627:therapeutic use; D002545:Brain Ischemia / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D002533:Cerebral Angiography; D003299:Cooperative Behavior; D065427:Factor Xa Inhibitors / Q000627:therapeutic use; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D018579:Patient Selection; D010414:Pennsylvania; D017410:Practice Guidelines as Topic; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D015912:Thrombolytic Therapy / Q000379:methods*; D061665:Time-to-Treatment / Q000592:standards; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed; D014481:United States; D014486:United States Food and Drug Administration
chemical_list: D000991:Antithrombins; D065427:Factor Xa Inhibitors; D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Acute ischemic stroke; IV rt-PA; Thrombolysis