Stroke IV tPA and Interventional Therapy Checklist

Yes No IV tPA Patient Selection Criteria (Inclusion Criteria) ❏ ❏ 1. Age 18 or over ❏ ❏ 2. Clinical diagnosis of ischemic stroke with a measurable neurological deficit. (NIHSS Score ______). ❏ ❏ 3. Time of "last known well" established to be less than 4.5 hours before treatment would begin. Last known well Date/Time: ______/ _____ : _____

Yes No Absolute Contraindications ❏ ❏ 1. Evidence of intracranial hemorrhage or major early infarct signs (e.g., substantial edema, mass effect, or midline shift) on pretreatment CT. ❏ ❏ 2. Clinical presentation suggestive of subarachnoid hemorrhage ❏ ❏ 3. Internal bleeding (e.g., GI/GU, hemoptysis, etc.) actively or within the last 3 weeks. ❏ ❏ 4. Known bleeding diathesis, including but not limited to: • Platelet count < 100,000 • Patient has received heparin within 48 hours and has an elevated aPTT at presentation • An elevated PT > 15 seconds or INR > 1.7 • Currently taking novel anticoagulant ❏ ❏ 5. Stroke, serious head trauma, intracranial or intraspinal surgery within 3 months ❏ ❏ 6. SBP > 185 or DBP > 110 despite aggressive treatment ❏ ❏ 7. Known intracranial neoplasm, arteriovenous malformation, or aneurysm ❏ ❏ 8. History of intracranial hemorrhage. (intra−parenchymal or subarachnoid) Yes No Warnings ❏ ❏ 1. Only minor or rapidly improving stroke symptoms (e.g., TIA) ❏ ❏ 2. Patients with severe neurological deficit (e.g., NIHSS > 22) at presentation ❏ ❏ 3. Currently receiving oral anticoagulants (e.g., warfarin) ❏ ❏ 4. Major surgery within past 14 days ❏ ❏ 5. Arterial puncture at non−compressible site or Lumbar puncture within past week ❏ ❏ 6. Abnormal blood glucose (<50 or > 400 mg/dL) ❏ ❏ 7. Acute pericarditis ❏ ❏ 8. Known subacute bacterial endocarditis ❏ ❏ 9. Significant hepatic or renal dysfunction ❏ ❏ 10. Female patient of child−bearing age with positive pregnancy test ❏ ❏ 11. Childbirth in the last 30 days ❏ ❏ 12. Diabetic hemorrhagic retinopathy or other hemorrhagic opthalmic conditions ❏ ❏ 13. High likelihood of left heart thrombus (mitral stnosis with atrial fibrillation) ❏ ❏ 14. AMI within last 3 months ❏ ❏ 15. Seizure at the onset Yes No 3 − 4.5 Hour Contraindications ❏ ❏ 1. Age > 80 ❏ ❏ 2. History of prior stroke AND diabetes ❏ ❏ 3. Any anticoagulant use prior to admission (even if INR < 1.7) ❏ ❏ 4. NIHSS > 25 Yes No Interventional Patient Selection Criteria (Inclusion Criteria) ❏ ❏ 1. ≥ 18 years of age ❏ ❏ 2. Pre−Stroke mRs 0−1 (Score Documented) ❏ ❏ 3. NIHSS ≥ 6 (Score Documented) ❏ ❏ 4. Aspects ≥ 6 (Score Documented) ❏ ❏ 5. Causative Occlusion of ICA or Proximal MCA (M1)

Signature Date Time

Stroke IV tPA and Interventional Therapy Checklist HWPN000003 Rev. 12/2015 Page 1 of 1 r*HWPN000003*r