Scope of Application
This guideline is intended for physicians working in emergency departments (EDs).

Inclusion Criteria
This guideline is intended for adult patients aged 18 years and older presenting to the ED with acute ischemic stroke.

Exclusion Criteria
This guideline is not intended to be used for pediatric or pregnant patients.

Critical Questions

1. Is IV tPA safe and effective for patients with acute ischemic stroke if given within 3 hours of symptom onset?
   
   Level B Recommendation:
   
   With a goal to improve functional outcomes, IV tPA should be offered and may be given to selected patients with acute ischemic stroke within 3 hours after symptom onset at institutions where systems are in place to safely administer the medication. The increased risk of symptomatic intracerebral hemorrhage (sICH) should be considered when deciding whether to administer IV tPA to patients with acute ischemic stroke.
   
   Level C Recommendation:
   
   When feasible, shared decision-making between the patient (and/or his or her surrogate) and a member of the health care team should include a discussion of potential benefits and harms prior to the decision whether to administer IV tPA for acute ischemic stroke. (Consensus recommendation)
   
   
   
2. Is IV tPA safe and effective for patients with acute ischemic stroke treated between 3 to 4.5 hours after symptom onset?
   
   Level B Recommendation:
   
   Despite the known risk of sICH and the variability in the degree of benefit in functional outcomes, IV tPA may be offered and may be given to carefully selected patients with acute ischemic stroke within 3 to 4.5 hours after symptom onset at institutions where systems are in place to safely administer the medication.
   
   Level C Recommendation:
   
   When feasible, shared decision-making between the patient (and/or his or her surrogate) and a member of the health care team should include a discussion of potential benefits and harms prior to the decision whether to administer IV tPA for acute ischemic stroke. (Consensus recommendation)
   
   
   

Disclaimer
Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician's judgment and patient preferences.