criteria for alteplase in community setting

from a highly placed stroke neurologist:
IA therapy has already been endorsed as reasonable in selected patients
by AHA/ASA, ACC  -  virtually all comprehensive stroke centers are doing
it. FDA approval is years away and is not required per se. IA case
selection variables have been quasi standardized: NIHSS > 10; major
vessel occlusion (M1/M2 MCA and basilar artery are favored sites for
intervention; carotid T and ICA occlusion somewhat more controversial
but doable); < 6 hours from stroke onset (some argue intervention should
be completed < 8 hours from stroke onset based on PROACT 2 . MERCI
retriever for clot removal is give
n as 8 hours); no standard thrombolytic exclusions. Many would add MR
or CT mismatch imaging as another selection factor especially as
you.approach 6 to 8 hours or in patients > 80 years of age with NIHSS >
20 (no standard criteria yet but 20% mismatch is probably too low; if
you had >50% mismatch and DW volume < 100 cc that would be favorable).
So until and unless you want to randomize into a (nonexistent) clinical
trial you.could simply not do IA (using the specious (in my view)
“unproven” argument) or you could have access to an experienced
comprehensive stroke center and do “drip and ship.”  You could
possibly develop IA at a certified primary stroke center if resources
(angio suite; interventionalist 24/7 etc) were available. Otherwise I do
not advocate IA stroke therapy at community hospitals. 

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