INSTRUCTIONS
Institutions may have slightly different absolute and relative contraindications to Tissue Plasminogen Activator (tPA); this list is meant to be a quick reference, but practice should be guided by institutional protocol and consultation with neurology. Reflects recommendations from Demaerschalk et al, Stroke 2015.
Clinical diagnosis of ischemic stroke causing neurological deficit
Time of symptom onset <4.5 hours
See Additional Warnings to tPA at 3-4.5hr below
Absolute Contraindications to tPA
Intracranial hemorrhage on CT
Clinical presentation suggests subarachnoid hemorrhage
Neurosurgery, head trauma, or stroke in past 3 months
Uncontrolled hypertension (>185 mmHg SBP or >110 mmHg DBP)
History of intracranial hemorrhage
Known intracranial arteriovenous malformation, neoplasm, or aneurysm
Suspected/confirmed endocarditis
Known bleeding diathesis
(1) Platelet count < 100,000; (2) Patient has received heparin within 48 hours and has an elevated aPTT (greater than upper limit of normal for laboratory); (3) Current use of oral anticoagulants (ex: warfarin) and INR >1.7; (4)Current use of direct thrombin inhibitors or direct factor Xa inhibitors
Abnormal blood glucose (<50 mg/dL)
Relative Contraindications/Warnings to tPA
Only minor or rapidly improving stroke symptoms
Major surgery or serious non-head trauma in the previous 14 days
History of gastrointestinal or urinary tract hemorrhage within 21 days
Recent arterial puncture at a noncompressible site
Post myocardial infarction pericarditis
Additional Warnings to tPA >3hr Onset
History of prior stroke and diabetes
Any active anticoagulant use (even with INR <1.7)
CT shows multilobar infarction (hypodensity >1/3 cerebral hemisphere)
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About the Creator
Edward C. Jauch, MD, MS, is a professor and director of emergency medicine at the Medical University of South Carolina. He was chair of Stroke Council for the American Heart Association/American Stroke Association and primary author for the new Acute Ischemic Stroke guidelines. Dr. Jauch conducts research in acute ischemic stroke care, biomarker development in cerebrovascular injuries and other neurologic emergencies.
To view Dr. Edward C. Jauch's publications, visit PubMed
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- Contraindications to Fibrinolytic Therapy
Contraindications to Fibrinolytic Therapy
Contraindications to Fibrinolytic Therapy
Absolute contraindications | Aortic dissection |
Previous hemorrhagic stroke (at any time) | |
Previous ischemic stroke within 1 year | |
Active internal bleeding (not menses) | |
Intracranial tumor | |
Pericarditis | |
Relative contraindications | Blood pressure > 180/110 mm Hg after initial antihypertensive therapy |
Trauma or major surgery within 4 weeks | |
Active peptic ulcer | |
Pregnancy | |
Bleeding diathesis | |
Noncompressible vascular puncture | |
Current anticoagulation (INR > 2) |