Contraindications for Intravenous Alteplase (tPA) in Acute Ischemic Stroke
Intracranial hemorrhage is an absolute contraindication to IV alteplase in acute ischemic stroke. AHA/ASA 2019 AIS Guideline (Table 8)
Alteplase should not be administered in patients with signs of subarachnoid hemorrhage or other conditions with a higher expected risk of serious bleeding than potential benefit. AHA/ASA 2019 AIS Guideline (Table 8) Activase (alteplase) Prescribing Information
Absolute Contraindications (AHA/ASA—Harm)
- Acute intracranial hemorrhage on brain imaging (CT reveals acute ICH) AHA/ASA 2019 AIS Guideline (Table 8)
- Subarachnoid hemorrhage (symptoms/signs most consistent with SAH) AHA/ASA 2019 AIS Guideline (Table 8)
- Prior ischemic stroke within 3 months AHA/ASA 2019 AIS Guideline (Table 8)
- Severe head trauma within 3 months AHA/ASA 2019 AIS Guideline (Table 8)
- Acute traumatic/posttraumatic infarction during the acute in-hospital phase AHA/ASA 2019 AIS Guideline (Table 8)
- Intracranial or intraspinal surgery within 3 months AHA/ASA 2019 AIS Guideline (Table 8)
- History of intracranial hemorrhage AHA/ASA 2019 AIS Guideline (Table 8)
- GI malignancy or GI bleed within 21 days AHA/ASA 2019 AIS Guideline (Table 8)
Coagulation-Related Contraindications (AHA/ASA—Harm)
- Platelets <100,000/mm³ AHA/ASA 2019 AIS Guideline (Table 8)
- INR >1.7 AHA/ASA 2019 AIS Guideline (Table 8)
- aPTT >40 seconds AHA/ASA 2019 AIS Guideline (Table 8)
-
PT >15 seconds AHA/ASA 2019 AIS Guideline (Table 8)
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LMWH (full treatment dose) within the previous 24 hours AHA/ASA 2019 AIS Guideline (Table 8)
Antithrombotic-Related Contraindications (AHA/ASA—Harm)
- Direct thrombin inhibitors or direct factor Xa inhibitors: IV alteplase should not be administered unless appropriate laboratory tests are normal or the patient has not received a dose for >48 hours (with normal renal metabolizing function). AHA/ASA 2019 AIS Guideline (Table 8)
- Concomitant abciximab (should not be administered concurrently with IV alteplase). AHA/ASA 2019 AIS Guideline (Table 8)
- Aspirin within 90 minutes after the start of IV alteplase (should not be administered). AHA/ASA 2019 AIS Guideline (Table 8)
Structural/Neoplastic/Infectious Contraindications (AHA/ASA—Harm)
- Infective endocarditis (symptoms consistent with infective endocarditis). AHA/ASA 2019 AIS Guideline (Table 8)
- Aortic arch dissection (known or suspected to be associated with aortic arch dissection). AHA/ASA 2019 AIS Guideline (Table 8)
- Intra-axial intracranial neoplasm (potentially harmful). AHA/ASA 2019 AIS Guideline (Table 8)
“No Benefit” Situations (AHA/ASA—Not Recommended)
- Mild nondisabling stroke (NIHSS 0–5) in a 0–3 hour window: IV alteplase is not recommended. AHA/ASA 2019 AIS Guideline (Table 8)
- Mild nondisabling stroke (NIHSS 0–5) in a 3–4.5 hour window: IV alteplase is not recommended. AHA/ASA 2019 AIS Guideline (Table 8)
- Extensive regions of “clear hypoattenuation” on CT: administering IV alteplase is not recommended. AHA/ASA 2019 AIS Guideline (Table 8)
Manufacturer Label Contraindications Relevant to Acute Stroke
- Current intracranial hemorrhage Activase (alteplase) Prescribing Information
- Subarachnoid hemorrhage Activase (alteplase) Prescribing Information
- Active internal bleeding Activase (alteplase) Prescribing Information
- Recent intracranial or intraspinal surgery or serious head trauma (within 3 months) Activase (alteplase) Prescribing Information
- Bleeding diathesis Activase (alteplase) Prescribing Information
- Current severe uncontrolled hypertension Activase (alteplase) Prescribing Information