Contraindications to Intravenous Alteplase (tPA) in Acute Ischemic Stroke
Intravenous alteplase should not be administered when contraindications are present, because the risk of symptomatic intracranial hemorrhage is increased. [1]
The following items are contraindications per the AHA/ASA 2019 guideline eligibility recommendations. [1]
Intracranial Hemorrhage and Imaging Findings
Acute intracranial hemorrhage on CT is a contraindication. [1]
Symptoms and signs most consistent with subarachnoid hemorrhage are a contraindication. [1]
Extensive regions of clear hypodensity on CT (severe established hypoxic/irreversible injury) are not recommended. [1]
A history of intracranial hemorrhage is a contraindication. [1]
Time-Critical Cerebrovascular, Head Trauma, and Recent Procedures
Use of intravenous alteplase after an ischemic stroke within 3 months is a contraindication. [1]
Recent severe head trauma within 3 months is a contraindication. [1]
Acute head trauma occurring during the posttraumatic infarction hospitalization/inpatient acute phase is a contraindication. [1]
Intracranial or intraspinal surgery within the prior 3 months is a contraindication. [1]
Active Bleeding Risk From Recent Gastrointestinal Disease
A structural gastrointestinal malignancy is a contraindication. [1]
A recent gastrointestinal bleeding event within 21 days is a contraindication. [1]
Hemorrhagic Diathesis and Coagulopathy Thresholds
Thrombocytopenia with platelets <100,000/mm³ is a contraindication. [1]
Elevated INR >1.7 is a contraindication. [1]
Elevated aPTT >40 seconds is a contraindication. [1]
Elevated PT >15 seconds is a contraindication. [1]
A full treatment dose of low-molecular-weight heparin (LMWH) within the previous 24 hours is a contraindication. [1]
Anticoagulant and Antiplatelet Contraindications
Intravenous alteplase is not recommended for patients taking direct thrombin inhibitors or direct factor Xa inhibitors unless laboratory testing shows normal coagulation parameters and/or the patient has not received a dose for >48 hours (assuming normal renal metabolism). [1]
Concomitant abciximab administration is a contraindication. [1]
Concomitant intravenous aspirin within 90 minutes after start of intravenous alteplase is a contraindication. [1]
Infectious and Vascular Structural Contraindications
Infective endocarditis (symptoms consistent with infective endocarditis) is a contraindication. [1]
Aortic arch dissection (known or suspected) is a contraindication. [1]
Neoplastic Contraindications
Intra-axial intracranial neoplasm is a contraindication. [1]