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Contraindications of intravenous tissue plasminogen activator
What are contraindications to intravenous tissue plasminogen activator?
Contraindications are based on the National Institute of Neurological Disorders and Stroke (NINDS) tPA trial: some, such as hemorrhage on CT head scan, are considered absolute, whereas others are relative.
The most frequent exclusion is time from when the patient was last seen normal (not when symptoms were discovered)—a particular problem for “wake-up strokes.”
Patients with minor/rapidly resolving deficits (possible TIAs) and seizure at stroke onset were excluded from the NINDS trial in order to avoid treating conditions that would return to baseline without thrombolysis.
However, patients may be left disabled by “mild” or “improving” strokes, and seizures complicate acute strokes approximately 15% of the time.
Wording on the package insert for IV tPA changed slightly in 2015. It is not yet clear whether this change will affect clinical guidelines.
Contraindications of Intravenous Tissue Plasminogen Activator
| Absolute Contraindications |
| Greater than 4.5 hours from the time patient was last seen normal |
| Initial head CT suggests time of onset is inaccurate |
| Suggestion of intracranial hemorrhage on pretreatment imaging |
| Subarachnoid hemorrhage |
| Intracerebral hemorrhage |
| Intracranial neoplasm or arteriovenous malformation |
| Active internal bleeding |
| Uncontrolled hypertension greater than 185/110 mm Hg despite antihypertensive treatment |
| Current bacterial endocarditis |
| Head trauma, intracranial/intraspinal surgery, or myocardial infarction within 3 months |
| Known bleeding diathesis:• INR > 1.7 or PT > 15 seconds• Platelets <100,000 mm 3• Heparin within 48 hours if PTT is elevated• PTT outside of the normal range• Dose of nonwarfarin oral anticoagulant within past 12 hours |
| Relative Contraindications |
| Minor or rapidly resolving deficits |
| Seizure |
| Major surgery in the previous 2 weeks |
| GI or urinary hemorrhage in the previous 3 weeks |
| Puncture at noncompressible site within 7 days (including lumbar puncture) |
PTT , Partial thromboplastin time; PT , prothrombin time; INR , international normalized ratio; GI , gastrointestinal; CT , computed tomography.
