Table 1.4.
Main contraindications for intravenous thrombolysis
| Unclear time of onset Unwitnessed symptom onset |
|
| Time of onset | Last known normal >4.5 ha |
| CT | Intracranial hemorrhage identified by CT Hypodensity >1/3 cerebral hemisphere |
| Vitals | Uncontrolled hypertension above 185/110 mmHg, despite use of antihypertensive agents |
| Anticoagulation | Therapeutic enoxaparin in the previous 24h (prophylactic dosing is not a contraindication) Current use of direct thrombin or factor Xa inhibitors (within 48 h) |
| History | Prior ischemic stroke within 3 months Severe head trauma within 3 months Intracranial/intraspinal surgery within 3 months Major surgery within past 14 days (including cesarean delivery) GI bleeding within 21 days Arterial puncture at noncompressible site within 7 days Note: lumbar puncture is NOT an absolute contraindication |
| Labs | Platelet <100,000/μL INR >1.7 PT > 15s aPTT >40s |
| Comorbidities | Infective endocarditis Intraaxial neoplasm Aortic arch dissection Structural GI malignancy |
a
The recently published EXTEND trial (Ma et al., 2019) and a subsequent meta-analysis (Campbell et al., 2014) suggest a benefit for thrombolysis in selected patients beyond the 4.5 h window, based on identification of patients with perfusion mismatch on imaging. However, this is not yet guideline-based standard of care.