Alteplase (tPA)

How it works

It is a recombinant tissue plasminogen activator that binds fibrin and converts plasminogen to plasmin, dissolving the occluding thrombus and restoring cerebral perfusion.

Prescribing in practice

• Intracranial haemorrhage is the major hazard, so haemorrhagic stroke must be excluded by imaging and strict eligibility, time-window, blood-pressure and contraindication criteria applied before treatment.
• It should only be given by clinicians trained in acute stroke care within an appropriate stroke pathway, after weighing time from symptom onset.
• Concurrent antithrombotics are withheld for a defined period after administration.

Monitoring

Monitor neurological status, blood pressure and for signs of bleeding closely during and after the infusion.

Counselling the patient

• This clot-busting treatment can improve stroke recovery but carries a risk of bleeding in the brain.
• Inform the team immediately of any new headache, drowsiness or worsening weakness.
• Report any bleeding, bruising or blood in urine or stool.

Evidence & guidelines

Intravenous alteplase for acute ischaemic stroke within the time window is recommended by NICE, based on the NINDS and subsequent thrombolysis trials.