2013 AHA Guidelines: Contraindications for Thrombolytics

Author: Michelle Lin, MD
Updated: 9/10/2010

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


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