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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.

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.
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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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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