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    tPA Contraindications for Ischemic Stroke

    Provides inclusion/exclusion criteria when deciding to use tPA on a patient with acute ischemic stroke.
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    INSTRUCTIONS

    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.

    When to Use
    Pearls/Pitfalls
    Why Use

    The list of absolute and relative contraindications to tPA should be reviewed in any patient with an acute ischemic stroke in whom thrombolysis is being considered.

    There are strict protocols concerning the appropriate administration of tPA in patients with ischemic stroke, including a list of absolute and relative contraindications.

    • Because of the risk of hemorrhage is thought to outweigh any potential benefits, patients with any absolute contraindication should not be given tPA.
    • For patients within the 3-hour window who meet the inclusion criteria and have no contraindications, earlier administration of tPA was associated with improved outcomes in one randomized trial (NINDS II).

    Points to keep in mind:

    • tPA for patients with acute ischemic stroke is associated with a significant increase in symptomatic intracranial hemorrhage, so it is essential to adhere to accepted protocols and to engage in shared decision making with the patient or their family when considering administering tPA.
    • The evidence and strength of recommendations for giving tPA in the 3-4.5 hour window is less robust than for giving thrombolytics inside the 180 minutes from onset of symptoms.

    The principal risk of tPA is symptomatic or fatal hemorrhage. It is essential that patients be evaluated for any history or risk factors that would put them at an increased risk of a hemorrhagic outcome.

    Eligibility for tPA
    Absolute Contraindications to tPA
    Relative Contraindications/Warnings to tPA
    Additional Warnings to tPA >3hr Onset
    About the Creator
    Dr. Edward C. Jauch
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    Evidence
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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.

    Formula

    Series of Yes/No questions.

    Facts & Figures

    For the entire list of inclusion/exclusion criteria, go to the Official NINDS website.

    For the National Stroke Guidelines, go to the Brain Attack website.

    Evidence Appraisal

    • The majority of the exclusion criteria are based on patients who were excluded from the original NINDS I and II trials. (Adams 1996)
    • Current guidelines suggest that tPA may be considered in patients with 1 or more relative contraindications, though only after making a considered risk/benefit analysis and in consultation with the patient and/or their family whenever possible. (Jauch 2013)
    • An article reviewing the literature found only 5 reports since 2006 of cardiac tamponade after receiving tPA for stroke, considering this and a review of data on natural history of cardiac healing after MI, the authors recommend that the current recommendation against tPA for patients with recent MI be shortened from 3 months to 7 weeks. (De Silva 2011)
    • There is a case report of a patient with seizures at stroke outset who received tPA after MRI confirmed acute ischemic stroke who had a good clinical outcome. The authors recommend using more advanced neuroimaging to identify patients with seizure who could safely be given tPA. (Selim 2003)

    Literature

    Dr. Edward C. Jauch

    About the Creator

    Edward C. Jauch, MD, MS, is a professor and director of emergency medicine at the Medical University of South Carolina. He was chair of Stroke Council for the American Heart Association/American Stroke Association and primary author for the new Acute Ischemic Stroke guidelines. Dr. Jauch conducts research in acute ischemic stroke care, biomarker development in cerebrovascular injuries and other neurologic emergencies.

    To view Dr. Edward C. Jauch's publications, visit PubMed

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