tPA Contraindications for Ischemic Stroke

Assesses inclusion/exclusion criteria for tPA in acute ischemic stroke patients.

Institutions may have slightly different absolute and relative contraindications to Tissue Plasminogen Activator (tPA); this list is meant to be a quick reference, but practice should be guided by institutional protocol and consultation with neurology. Reflects recommendations from Demaerschalk et al, Stroke 2015.

Eligibility for tPA

Age ≥18

Clinical diagnosis of ischemic stroke causing neurological deficit

Time of symptom onset <4.5 hours

See Additional Warnings to tPA at 3-4.5hr below

Absolute Contraindications to tPA

Intracranial hemorrhage on CT

Clinical presentation suggests subarachnoid hemorrhage

Neurosurgery, head trauma, or stroke in past 3 months

Uncontrolled hypertension (>185 mmHg SBP or >110 mmHg DBP)

History of intracranial hemorrhage

Known intracranial arteriovenous malformation, neoplasm, or aneurysm

Active internal bleeding

Suspected/confirmed endocarditis

Known bleeding diathesis

(1) Platelet count <100,000.
(2) Patient has received heparin within 48 hours and has an elevated aPTT (greater than upper limit of normal for laboratory).
(3) Current use of oral anticoagulants (ex: warfarin) and INR >1.7.
(4) Current use of direct thrombin inhibitors or direct factor Xa inhibitors.

Abnormal blood glucose (<50 mg/dL)

Intra-axial intracranial neoplasm

Gastrointestinal (GI) malignancy

Intracranial or intraspinal surgery within the last 3 months

CT brain imaging shows extensive regions of clear hypoattenuation

Stroke is known or suspected to be associated with aortic arch dissection

Relative Contraindications/Warnings to tPA

Only minor or rapidly improving stroke symptoms

Major surgery or serious non-head trauma in the previous 14 days

History of gastrointestinal or urinary tract hemorrhage within 21 days

Seizure at stroke onset

Recent arterial puncture at a noncompressible site

Recent lumbar puncture

Post myocardial infarction pericarditis

Pregnancy

Additional Warnings to tPA >3hr Onset

Age >80 years

History of prior stroke and diabetes

Any active anticoagulant use (even with INR <1.7)

NIHSS >25

CT shows multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Result:

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Management

In patients who present with symptoms concerning for ischemic stroke:

Consult neurology.
Determine the onset of stroke symptoms (or time patient last felt or was observed normal).
Obtain a stat head CT to evaluate for hemorrhagic stroke.
In appropriate circumstances and in consultation with both neurology and the patient, consider IV thrombolysis for ischemic strokes in patients with no contraindications.

Critical Actions

Patients presenting with a potential acute ischemic stroke should have a non-contrast CT scan of the head performed as soon as is safely possible.
If the patient is a candidate for thrombolysis with tPA they should be carefully evaluated for any absolute or relative contraindications.
The NIHSS should be performed as part of their evaluation, by a NIHSS certified provider if one is available.
While a high NIHSS score (>22) is not an absolute contraindication to tPA within the 3 hour window, be aware that the rate of symptomatic or fatal intracranial hemorrhage is higher among this cohort.
If the patient has an elevated blood pressure (SBP >185 or DBP >110) as their only contraindication to receiving tPA, consider using parenteral medication to lower their blood pressure to an acceptable level. If the blood pressure can be adequately controlled, the patient may be safely given tPA if they meet the inclusion criteria and have no other contraindications.
When considering giving tPA in the extended window (3-4.5 hours), remember that an NIHSS score of >25 is considered a contraindication to thrombolysis.

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