Contraindications to Intravenous Thrombolysis (IVT) for Ischemic Stroke

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.

• Suggested dosing for tenecteplase is 0.25mg/kg (max dose 25mg).

• Suggested dosing for alteplase is 0.9mg/kg.

IV thrombolysis can also be considered in some individuals who have symptoms of acute ischemic stroke and imaging evidence of salvageable ischemic penumbra by automated perfusion imaging or MRI-based diffusion weighted imaging and FLAIR mismatch in extended or uncertain time windows:

• Awakening with stroke symptoms within 9 hours from the midpoint of sleep or are 4.5-9 hours from last known well.

• 4.5-24 hours from symptom onset due to large vessel occlusion (LVO) but unable to receive endovascular thrombectomy and who are under direction of thrombolytic stroke care experts.

• Unknown symptom onset but within 4.5 hours of symptom recognition.

• 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 IVT 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.
• If the patient has an elevated blood pressure (SBP >185 or DBP >110) as their only contraindication to receiving IVT, 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 IVT if they meet the inclusion criteria and have no other contraindications.