Stroke: 2013 AHA Guidelines on Contraindications for Thrombolytics

Inclusion Criteria

1. Diagnosis of ischemic stroke causing measurable neurologic deficit
2. Age ≥18 years

Exclusion Criteria

0-3 hours from symptom onset

Absolute Exclusion Criteria

• Significant head trauma or prior stroke in previous 3 months
• Symptoms suggest subarachnoid hemorrhage
• Arterial puncture at noncompressible site in previous 7 days
• History of previous intracranial hemorrhage
• Intracranial neoplasm, AV malformation, or aneurysm
• Recent intracranial or intraspinal surgery
• Elevated BP (SBP >185 mmHg or DBP >110 mmHg)
• Active internal bleeding
• Acute bleeding diathesis (Platelet count <100,000/mm3; Heparin received within 48 hours, resulting in aPTT above upper limit of normal)
• Current use of anticoagulant with INR >1.7 or PT > 15 sec
• Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive lab tests (such as aPTT, INR, platelet, and ecarin clotting time; TT; or appropriate factor Xa activity assays)
• Blood glucose <50 mg/dL (2.7 mmol/L)
• CT shows multilobar infarct (hypodensity >1/3 cerebral hemisphere)

Relative Exclusion Criteria

• Only minor or rapidly improvement stroke symptoms (clearing spontaneously)
• Pregnancy
• Seizure at onset with postictal residual neurologic impairments
• Major surgery or serious trauma within previous 14 days
• Recent GI or urinary tract hemorrhage within previous 21 days
• Recent acute MI within previous 3 months

3-4.5 hours from symptom onset

Absolute Exclusion Criteria

List is same as for 0-3 hour time frame above PLUS any of the following:

• Age >80 years
• Severe stroke (NIHSS >25)
• Taking oral anticoagulant regardless of INR
• History of both diabetes mellitus AND prior ischemic stroke

References

• Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar;44(3):870-947. PMID: 23370205. [Source]
• NINDS rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995 Dec 14;333(24):1581-7. [Source]