• Rule-out clinical situations that may mimic a cerebral vascular accident (e.g., hypoglycemia, seizures, migraine with an aura, hypertensive or Wernicke’s encephalopathy, CNS tumor, drug toxicity [e.g., lithium, phenytoin])

• Airway support and ventilatory assistance in patients with a depressed level of consciousness or airway compromise

• Supplemental oxygen in hypoxic patients (maintain oxygen saturation >94 %)

• Antipyretics and cooling devices for the management of fever

• Antihypertensive agents should be avoided unless the systolic blood pressure is >220 mmHg or the diastolic blood pressure is >120 mmHg (see Table 3.2 for management)

      ○     ○ Patients who are otherwise eligible (except blood pressure) for alteplase should have their blood pressure lowered cautiously to a systolic ≤185 mmHg and a diastolic ≤110 mmHg. Note: once tPA is administered, the blood pressure must be maintained below 180/105 mmHg to limit the risk of ICH

• Treat hypotension with intravenous normal saline

• Avoid/treat hypoglycemia (<60 mg/dL)

• Control hyperglycemia

      ○     ○ Target blood glucose levels 140–180 mg/dL

      ○       ○       ■ Optimal blood glucose range is not well delineated

      ○       ○       ■ Frequent monitoring of blood glucose levels and adjustments of insulin are required to avoid hypoglycemia

Patient not eligible for alteplase

• Systolic blood pressure (SBP) ≤220 mmHg or diastolic blood pressure (DBP) ≤120 mmHg

      ○     ○ Observe (unless other end-organ damage present)

• SBP >220 mmHg or DBP between 121 and 140 mmHg

      ○     ○ Aim for a 10–15 % reduction in MAP

      ○     ○ Labetolol 10–20 mg IV over 1–2 min. May repeat or double every 10 min (maximum 300 mg)

      ○     ○ Nicardipine 5 mg/h continuous IV infusion. Titrate by 2.5 mg/h increments every 5–15 min to a maximum of 15 mg/h

• DBP >140 mmHg

      ○     ○ Aim for a 10–15 % reduction in mean arterial pressure (MAP)

      ○     ○ Nitroprusside—0.25–0.5 mcg/kg/min continuous IV infusion; increase in increments of 0.25–0.5 mcg/kg/min until desired hemodynamic effect. Usual doses up to 2–3 mcg/kg/min. High-alert medication—read package insert before use

Patient otherwise eligible for alteplase ( except for blood pressure )

• SBP >185 mmHg or DBP >110 mmHg confirmed by two consecutive measurements

      ○     ○ Labetolol 10–20 mg IV over 1–2 min. May repeat X one dose

      ○     ○ Nicardipine 5 mg/h continuous IV infusion. Titrate by 2.5 mg/h increments every 5–15 min to a maximum of 15 mg/h

      ○     ○ If blood pressure is not reduced and maintained at target range (systolic ≤185 mmHg and diastolic ≤110 mmHg), do not administer fibrinolytic

      ○       ○       ■ Aggressive treatment to reduce and maintain blood pressure excludes patients from fibrinolytic eligibility. Patients that require sodium nitroprusside to control blood pressure may not be sufficiently stable to receive fibrinolytic pharmacotherapy

      ○     ○ Blood pressure control during and after fibrinolytic administration is SBP <180 mmHg and DBP <105 mmHg

During and after fibrinolytic therapy

• Monitor blood pressure every 15 min for 2 h from the start of tPA, then every 30 min for 6 h, then every hour for 16 h

• If blood pressure increases above target range

      ○     ○ DBP >140 mmHg

      ○       ○       ■ Nitroprusside—0.25–0.5 mcg/kg/min continuous IV infusion; increase in increments of 0.25–0.5 mcg/kg/min until desired hemodynamic effect. Usual doses up to 2–3 mcg/kg/min. High-alert medication—read package insert before use

      ○     ○ SBP >180–230 mmHg or DBP between 105 and 140 mmHg

      ○       ○       ■ Labetolol 10–20 mg IV over 1–2 min. May repeat or double every 10 min (maximum 300 mg). Alternatively, a continuous IV infusion (2–8 mg/min) may be initiated after the initial bolus

      ○       ○       ■ Nicardipine 5 mg/h continuous IV infusion. Titrate by 2.5 mg/h increments every 5–15 min to a maximum of 15 mg/h

      ○       ○       ■ If blood pressure not controlled, may consider nitroprusside

Inclusion criteria

• Age ≥ 18 years

• Clinical diagnosis of an acute ischemic cerebrovascular accident (CVA) causing a measurable neurological deficit

• Ability to definitively establish the time of CVA onset

• Ability to begin alteplase therapy within 3 h (up to 4.5 h) of CVA onset

• Patient or family members understand the potential risks and benefits from treatment

Exclusion criteria

• Evidence of intracranial hemorrhage, subarachnoid hemorrhage, or a large area of cerebral edema, parenchymal hypodensities, or sulcal effacement on pretreatment head CT scan

• Head CT shows a multilobar infarction/hypodensity involving more than one-third of the cerebral hemisphere

• History of any intracranial hemorrhage

• Known arteriovenous malformation, aneurysm, or intracranial neoplasm

• Active internal bleeding

• Platelet count <100,000/mm³

• Patient is coagulopathic or has received heparin within the past 48 h and has an elevated activated partial thromboplastin time (aPTT) greater than the upper limit of normal

• Patient is coagulopathic or has recently received an oral anticoagulant (e.g., warfarin) and has an elevated international normalized ratio (INR) > 1.7