tPA Contraindications for Ischemic Stroke

Why Use

The principal risk of tPA is symptomatic or fatal hemorrhage. It is essential that patients be evaluated for any history or risk factors that would put them at an increased risk of a hemorrhagic outcome.

When to Use

The list of absolute and relative contraindications to tPA should be reviewed in any patient with an acute ischemic stroke in whom thrombolysis is being considered.

Formula

Pearls / Pitfalls

There are strict protocols concerning the appropriate administration of tPA in patients with ischemic stroke, including a list of absolute and relative contraindications. Because of the risk of hemorrhage is thought to outweigh any potential benefits, patients with any absolute contraindication should not be given tPA. For patients within the 3-hour window who meet the inclusion criteria and have no contraindications, earlier administration of tPA was associated with improved outcomes in one randomized trial (NINDS II). Points to keep in mind: tPA for patients with acute ischemic stroke is associated with a significant increase in symptomatic intracranial hemorrhage, so it is essential to adhere to accepted protocols and to engage in shared decision making with the patient or their family when considering administering tPA. The evidence and strength of recommendations for giving tPA in the 3-4.5 hour window is less robust than for giving thrombolytics inside the 180 minutes from onset of symptoms.

Management

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.

More Information

For the entire list of inclusion/exclusion criteria and ischemic stroke guidelines, view the 2019 Update in Early Management of Acute Ischemic Stroke .