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