Quick visual reference of absolute and relative contraindications to thrombolytic treatment in acute ischemic stroke.
Intravenous thrombolysis should not be administered to patients whose brain imaging reveals regions of clear hypodensity that appear to be responsible for the patient's clinical stroke symptoms.
Clear hypodensity is defined as a degree of hypodensity greater than the density of the unaffected contralateral white matter.
Intravenous thrombolysis should not be administered to patients whose CT brain imaging reveals an acute intracranial hemorrhage.
Intravenous thrombolysis is likely contraindicated in patients with acute ischemic stroke and recent moderate-to-severe traumatic brain injury (within the last 14 days) that caused >30 minutes of loss of consciousness and a Glasgow Coma Scale <13, or evidence of hemorrhage, contusion, or skull fracture on neuroimaging.
For patients with acute ischemic stroke and a history of intracranial or spinal surgery within the last 14 days, IV thrombolysis is potentially harmful and should not be administered.
Intravenous thrombolysis is likely contraindicated in patients with acute ischemic stroke and spinal cord injury within the last 3 months.
For patients with acute ischemic stroke harboring an intra-axial intracranial neoplasm, treatment with IV thrombolysis is potentially harmful and should not be administered.
For patients with acute ischemic stroke and symptoms consistent with infective endocarditis, IV thrombolysis should not be administered, given the risk of hemorrhage from septic emboli and mycotic aneurysms.
The safety and efficacy of IV thrombolysis in patients with platelets <100,000/mm³, INR >1.7, aPTT >40 s, or PT >15 s is unknown; it may substantially increase the risk of harm and should not be administered.
In patients without recent warfarin or heparin use, treatment may be initiated before coagulation test results are available, but it should be discontinued if INR >1.7, or PT or PTT are abnormal according to local laboratory standards.
For patients with acute ischemic stroke and known or suspected aortic arch dissection, treatment with IV thrombolysis is potentially harmful and should not be administered.
The risk of thrombolysis-related intracerebral hemorrhage in patients receiving amyloid immunotherapy or with amyloid-related imaging abnormalities (ARIA) is unknown; IV thrombolysis should be avoided in these patients.
The benefits versus risks of offering IV thrombolysis in patients with preexisting disability or frailty remain uncertain. Treatment should be determined on an individualized basis.
In patients with disabling symptoms and recent DOAC exposure (<48 h) who fall within the alteplase or tenecteplase window, the safety of IV thrombolysis is unknown. Emerging but limited observational data suggest that it may be considered after a thorough individualized benefit-risk assessment.
Assessments should include timing of the last DOAC dose, renal function, stroke severity, availability of endovascular thrombectomy, availability of reversal agents (idarucizumab, andexanet alfa), and DOAC-specific thrombin time or anti-factor Xa assays, recognizing the potential delay in thrombolysis and increased thrombotic risk.
All aspects of DOAC management (timing, use of reversal agents, assay results) should be carefully documented. Definitive clinical trials are needed to establish safety.
The use of IV thrombolysis in patients with a prior ischemic stroke within the last 3 months may carry an increased risk of intracranial hemorrhage. The potential increase in risk based on timing and size of the prior stroke should be weighed against the benefits on an individualized basis.
Administration of IV thrombolysis in patients with a history of intracerebral hemorrhage may increase the risk of symptomatic hemorrhage.
Patients with known amyloid angiopathy may be considered at higher risk than patients whose intracerebral hemorrhage was due to modifiable conditions (HTN, coagulopathy). IV thrombolysis may have benefit greater than risk in the latter. Treatment should be determined on an individualized basis.
Patients with recent major trauma between 14 days and 3 months of the acute ischemic stroke may be at increased risk of harm and severe systemic hemorrhage requiring transfusion. Individual risk-benefit consideration, the areas involved, and consultation with surgical experts are appropriate.
Patients with recent major surgery within the last 10 days of the acute ischemic stroke may be at increased risk of harm. Individual risk-benefit consideration, the surgical area, and consultation with surgical experts are appropriate.
Patients with recent gastrointestinal or genitourinary hemorrhage within the last 21 days may be at increased risk of harm. Consultation with gastroenterology or urology specialists is recommended to determine whether the hemorrhage has been treated and the risk has been modified.
The safety of IV thrombolysis in patients with acute ischemic stroke due to intracranial arterial dissection is unknown.
The safety of IV thrombolysis is unknown for patients presenting with acute ischemic stroke who are known to harbor an unruptured and untreated intracranial vascular malformation.
Patients with recent STEMI may be at risk of increased harm. For STEMI within the last 3 months, individual risk-benefit consideration should be determined in conjunction with emergent cardiology consultation.
For very recent STEMI (within the last few days), the risk of hemopericardium should be considered in relation to the potential benefit.
For acute ischemic stroke concurrent with acute STEMI, treatment should be at the dose appropriate for cerebral ischemia and in conjunction with emergent cardiology consultation. Consideration of timing, type, and severity of the STEMI is warranted.
IV thrombolysis for patients with a major acute ischemic stroke likely to produce severe disability and acute pericarditis may be reasonable in individual cases. Emergent cardiology consultation is warranted.
IV thrombolysis for patients with known left atrial or ventricular thrombus presenting with a major acute ischemic stroke likely to produce severe disability may be reasonable in individual cases. Emergent cardiology consultation is warranted.
The safety of IV thrombolysis in patients with active systemic malignancy is unknown. Emergent oncology consultation is warranted to assess risk-benefit, considering the type, stage, and active complications of the cancer.
IV thrombolysis may be considered in pregnancy and the postpartum period when the benefits of treating a moderate or severe stroke outweigh the anticipated risk of uterine hemorrhage. Emergent obstetric consultation is warranted.
IV thrombolysis for patients with acute ischemic stroke after dural puncture may be considered in individual cases, even in instances where they may have undergone a lumbar dural puncture in the preceding 7 days.
The safety of IV thrombolysis in patients with acute ischemic stroke who have had an arterial puncture of a non-compressible blood vessel (e.g., subclavian arterial line) within the 7 days prior to stroke symptoms is unknown.
IV thrombolysis may be considered in patients with acute ischemic stroke and recent moderate-to-severe TBI (between 14 days and 3 months). Careful consideration should be given based on the type and severity of the traumatic injury and in consultation with the neurosurgery and neurocritical care teams.
For patients with acute ischemic stroke and a history of intracranial or spinal surgery between 14 days and 3 months, IV thrombolysis may be considered on an individual basis. Consultation with members of the neurosurgical team is recommended.