Initial Assessment:

  • Obtain Vitals and blood glucose level
  • Time of onset (important for tPA/TNK vs thrombectomy)
  • Neurologic and Cardiac Examination / NIHSS
    • do not delay head CT to complete NIHSS, can always finish after CT
  • Assess contraindications for tPA


  • Labs: CBC, CMP, Troponin, Coags, EtOH, bedside accucheck
  • CXR and UA (infections can cause recrudescence of prior cva)
  • ECG looking specifically for AFib
  • Stat Imaging: CT Head noncontrast, followed by CTA Head/Neck and/or CT Perfusion


  • tPA / TNK if significant neurologic deficits are present and no contraindications exist
  • Thrombectomy if large vessel occlusion present without contraindications
  • Admission to stroke unit to…
    • Workup the etiology of stroke (usually carotid US, Echo /w bubble study, telemetry monitoring),
    • Optimize treatment of risk factors such has HLD, HTN, AFib, etc
    • Obtain early PT/OT/Rehab

Post-tPA Complications: Angioedema (2-5%) and Hemorrhage (2-7%)

  • Have a high index of suspicion for hemorrhage – monitor for headaches, change in mental status, signs of ICP, etc
  • Stop tPA immediately
  • If concerned for hemorrhage, elevate head of bed and obtain STAT CT Head
  • For hemorrhage, consider TXA, Platelets, Cryoprecipitate (as recommended by the AHA, however evidence is extremely poor) and consult Neurosurgery
  • For Angioedema, monitor airway closely, intubate if necessary, and consider medical treatment (FFP, Antihistamines, Steroids, Epinephrine, TXA – all of which have poor evidence for benefit)

Further Reading:

MD Calc- tPA Contraindications

EMDocs – Post tPA Complications

EMRA – Post tPA Hemorrhage