tPA_Contraindications_for_Ischemic_Stroke_guideline v.0

Age

Clinical diagnosis of ischemic stroke causing neurological deficit

Time of symptom onset <4.5 hours

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

Active internal bleeding

Suspected/confirmed endocarditis

Known bleeding diathesis

Abnormal blood glucose (<50 mg/dL)

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

Seizure at stroke onset

Recent arterial puncture at a noncompressible site

Recent lumbar puncture

Post myocardial infarction pericarditis

Pregnancy

History of prior stroke and diabetes

Any active anticoagulant use (even with INR <1.7)

NIHSS >25

CT shows multilobar infarction (hypodensity >1/3 cerebral hemisphere)

tPA treatment Contraindications guideline for Ischemic Stroke

Frank Ogiemwonyi

frank.ogiemwonyi@stud.ki.se

To provide inclusion/exclusion criteria when deciding to use tPA on a patient with acute ischemic stroke. tPA for patients with acute ischemic stroke is associated with a significant increase in symptomatic intracranial hemorrhage, so it is essential to adhere to accepted protocols and to engage in shared decision-making with the patient or their family when considering administering tPA.

To review the list of absolute and relative contraindications to tPA in any patient with an acute ischemic stroke in whom thrombolysis is being considered. It is essential that patients be evaluated for any history or risk factors that would put them at an increased risk of a hemorrhagic outcome. There are strict protocols concerning the appropriate administration of tPA in patients with ischemic stroke, including a list of absolute and relative contraindications. Because of the risk of hemorrhage is thought to outweigh any potential benefits, patients with any absolute contraindication should not be given tPA. For patients within the 3-hour window who meet the inclusion criteria and have no contraindications, earlier administration of tPA was associated with improved outcomes in one randomized trial (NINDS II). *FORMULA The formula works with a series of Yes/No questions. Points to keep in mind: The evidence and strength of recommendations for giving tPA in the 3-4.5 hour window is less robust than for giving thrombolytics inside 180 minutes from the onset of symptoms.

it should not be used when time of acute ischemic stroke symptom onset is >4.5 hours or when patient is less than 18 years old

1. Adams HP, Brott TG, Furlan AJ, Gomez CR, Grotta J, Helgason CM, et al. Guidelines for Thrombolytic Therapy for Acute Stroke: A Supplement to the Guidelines for the Management of Patients With Acute Ischemic Stroke. Circulation [Internet]. 1996 Sep [cited 2022 Mar 25];94(5):1167–74. Available from: https://www.ahajournals.org/doi/full/10.1161/01.cir.94.5.1167 2. Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ (Buddy), Demaerschalk BM, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke [Internet]. 2013 Mar [cited 2022 Mar 25];44(3):870–947. Available from: https://www.ahajournals.org/doi/full/10.1161/str.0b013e318284056a 3. De Silva DA, Manzano JJ, Chang HM, Wong MC. Reconsidering recent myocardial infarction as a contraindication for IV stroke thrombolysis. Neurology. 2011 May 24;76(21):1838-40. doi: 10.1212/WNL.0b013e31821ccc72. Epub 2011 Apr 13. 4. Selim M, Kumar S, Fink J, Schlaug G, Caplan LR, Linfante I. Seizure at stroke onset: should it be an absolute contraindication to thrombolysis? Cerebrovasc Dis. 2002;14(1):54-7. doi: 10.1159/000063724.

openEHR-EHR-OBSERVATION.basic_demographic, openEHR-EHR-EVALUATION.tissue_plasminogen_activator_tpa_administration, openEHR-EHR-EVALUATION.recommendation_tpa_contraindication

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