STROKE PHYSICIAN

CLINICAL DECISION FORM

STROKE PHYSICIAN CLINICAL DECISION FORM

EXCLUSION CRITERIA FOR INTRAVENOUS rt-PA

NIHSS STROKE ASSESSMENT FORM

STROKE PHYSICIAN
CLINICAL DECISION

PATIENT NAME:

Therapeutic decision

1. Diagnosis

Clinical Presentation:

CT Imaging Observations:

Hyperdense artery sign Yes No

Side

% of MCA Region damaged <1/3 >1/3

ASPECTS Score

CTA

2. Bleed/No Bleed

Evidence of Bleeding on the CT scan Yes No

3. Severity

NIHSS Score

Glasgow Coma Scale

mRS pre-stroke

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 STROKE PHYSICIAN CLINICAL DECISION

4. Contraindications

Problems Consideration Contraindication?

Yes No

Yes No

Yes No

Yes No

Time since last seen normal Yes No

Blood pressure Yes No

Blood Glucose Yes No

INR Yes No

5. Therapeutic Priorities

Hyperacute (0-1 h) Acute (1-24 h) Postacute (24-72 h)

Therapeutic decision

rt-PA General supportive therapy Haemorrhagic stroke

Thrombectomy TIA Mimic

Reason for therapeutic decision

Please note that the above recommendations are based on the European Stroke Organisation guidelines 2008/update 2009. Please check your local regulations and prescribing information.
Reference: European Stroke Organisation (ESO). Cerebrovasc Dis 2008;25(5):457-507.
 EXCLUSION CRITERIA FOR INTRAVENOUS rt-PA

ALL points of the checklist must be answered with NO for the patient to be treated with intravenous rt-PA. If any of the following points are
answered with YES; treatment with intravenous rt-PA is contraindicated.

Contraindications for rt-PA

Contraindications associated with a high risk of haemorrhage such as: Yes No

Known haemorrhagic diathesis

Patients receiving oral anticoagulants, e.g. warfarin sodium
Manifest or recent severe or dangerous bleeding
Known history of or suspected intracranial haemorrhage
Suspected subarachnoid haemorrhage or condition after subarachnoid haemorrhage from aneurysm
Any history of central nervous system damage (i.e. neoplasm, aneurysm, intracranial or spinal surgery)
Recent (less than 10 days) traumatic external heart massage, obstetrical delivery, recent puncture of a non-
compressible blood vessel (e.g. subclavian or jugular vein puncture)
Severe uncontrolled arterial hypertension
Bacterial endocarditis, pericarditis
Acute pancreatitis
Documented ulcerative gastrointestinal disease during the last 3 months, oesophageal varices, arterial aneurysm,
arterial/venous malformations
Neoplasm with increased bleeding risk
Severe liver disease, including hepatic failure, cirrhosis, portal hypertension (oesophageal varices) and active hepatitis
Major surgery or significant trauma in past 3 months
Evidence of intracranial haemorrhage (ICH) on the CT-scan
Symptoms suggestive of subarachnoid haemorrhage, even if CT-scan is normal
Administration of heparin within the previous 48 hours and a thromboplastin time exceeding the upper limit of normal
for laboratory
Prior stroke within the last 3 months
Platelet count of below 100,000/mm3
Systolic blood pressure >185 or diastolic BP >110 mmHg, or aggressive management (IV medication) necessary to
reduce BP to these limits

Contraindication based on time:

Symptoms of ischaemic attack beginning more than 4.5 hours prior to infusion start or when time of symptoms for
which the onset time is unknown and could potentially be more than 4.5 hours ago

Contraindications based on stroke severity:

Minor neurological deficit or symptoms rapidly improving before start of infusion

Severe stroke as assessed clinically (e.g. NIHSS >25) and/or by appropriate imaging techniques

Contraindication related to age:

Children under 16 years

Additional contraindications:

Seizure at onset of stroke

Any history of prior stroke and concomitant diabetes
Blood glucose <50 or >400 mg/dl

Reference: Actilyse® Summary of Product Characteristics, labelling and package leaflet, Version: September 2019
 RAPID STROKE
ASSESSMENT
NIHSS Stroke Scale
Short version1

Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change
scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient
can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be
coached (i.e., repeated requests to patient to make a special effort).

Score
Admission 72 hours discharge

0 = Awake
1 = Drowsy
1a Consciousness 2 = Stuporous
3 = Comatose

0 = Month, age correct at first attempt

1 = One correct, or intubated, severe dysarthria or language
1b Orientation
barrier
2 = None correct or aphasic or comatose

0 = Obeys both correctly

1c Following commands 1 = Obeys one

2 = Does not obey either command, or comatose

0 = Normal
1 = Partial peripheral paresis (N. III, IV, VI) or deviation
2 Gaze that can be overcome
2 = Fixed deviation

0 = Normal
1 = Quadrant anopia or extinction
3 Visual field 2 = Complete hemianopia
3 = Blindness

0 = Normal
1 = Slight central paresis, flattened nasolabial fold
4 Facial movement 2 = Clear central paresis or paralysis
3 = Bilateral or peripheral paresis or coma

0 = Arm held up normally for 10 seconds

1 = Arm slowly drifts partway down
5a Holding up left arm 2 = Arm quickly drifts all the way down
3 = Arm falls down
4 = No movement or coma

0 = Arm held up normally for 10 seconds

1 = Arm slowly drifts partway down
5b Holding up right arm 2 = Arm quickly drifts all the way down
3 = Arm falls down
4 = No movement or coma

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 RAPID STROKE ASSESSMENT – NIHSS Stroke Scale (short version)

Score
Admission 72 hours discharge

0 = Leg held up normally for 5 seconds

1 = Leg slowly drifts partway down
6a Holding up left leg 2 = Leg quickly drifts all the way down
3 = Leg falls down
4 = No movement or coma

0 = Leg held up normally for 5 seconds

1 = Leg slowly drifts partway down
6b Holding up right leg 2 = Leg quickly drifts all the way down
3 = Leg falls down
4 = No movement or coma

0 = No ataxia, Pat. does not understand, paralysis

or coma
7 Ataxia 1 = Ataxia in 1 limb
2 = Ataxia in 2 limbs

0 = Normal
8 Sensitivity 1 = Mild sensory loss
2 = Total sensory loss or coma

0 = Normal
1 = Difficulty finding words, mild aphasia
9 Language 2 = Clear difficulties in conversation
3 = Global aphasia, Patient mute or comatose

0 = No dysarthria
1 = Dysarthria, can be understood well
10 Dysarthria
2 = Dysarthria, scarcely intelligible or Pat. does
not answer, or coma

0 = No abnormality
1 = Extinction of one sensory modality or other signs of neglect
11 Extinction 2 = Extinction of more than one sensory modality or coma

Total

ED physician, name Staff number Signature Date

Time

Reference: 1. http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf 2. Neuroepidemiology. 2006;26(1):4-15. Epub 2005 Nov 3. Decision Form_PDF_EN_190705_v06