Reperfusion Therapy – Contraindications

There is a long list of contra-indications for thrombolysis of acute ischaemic stroke with alteplase, as listed in the manufacturer’s summary of product characteristics.

Imaging

Contra-indications found on brain imaging include:

  • Intracranial haemorrhage
  • Greater than one-third middle cerebral artery territory acute ischaemic change (i.e. very severe stroke)
  • Extensive small vessel disease

History

Contra-indications from history include:

  • Symptoms began more than 4.5 hours prior to thrombolysis, or unknown time of onset
  • Patient already receiving effective oral anticoagulation treatment
  • Seizure at stroke onset
  • History of stroke or head injury in the last three months
  • History of any previous stroke and concomitant diabetes
  • History of any previous intracranial haemorrhage
  • History consistent with subarachnoid haemorrhage (even if CT is normal)
  • History of previous major surgery or significant trauma in the last 3 months
  • Previous CNS damage (including spinal/intracranial surgery, neoplasm or aneurysm)
  • History of gastrointestinal or urinary tract haemorrhage within 21 days or documented ulcerative gastrointestinal disease in the last 3 months
  • Recent (less than 10 days) arterial puncture at a non-compressible site (subclavian/ jugular vein)
  • Recent (less than 10 days) traumatic external heart massage or obstetrical delivery
  • Recent lumbar puncture
  • Heparin treatment within last two days
  • Severe liver disease, acute pancreatitis, neoplasm with increased bleeding risk
  • Significant bleeding disorder at present or within the past 6 months, or known haemorrhagic diathesis

Investigations

Contra-indications from investigations include:

  • Platelets <100*109/l
  • INR >1.7/elevated thromboplastin time
  • Blood glucose < 50 or > 400 mg/dl

Examination

Contra-indications from examination include:

  • Symptoms rapidly improving
  • Low NHISS score (four or less) or very high NIHSS score (25 or more)
  • Systolic blood pressure consistently >185mmHg

Diastolic blood pressure consistently >110mmHg