Can tissue plasminogen activator (tPA) be administered to a patient with a history of intracerebral hemorrhage?

From the Guidelines

Recombinant tissue plasminogen activator (rtPA) is generally contraindicated in patients with a history of intracerebral hemorrhage (ICH) due to the significantly increased risk of potentially fatal bleeding complications. This contraindication is based on the standard treatment protocols for acute ischemic stroke, as outlined in the guidelines from the American Heart Association/American Stroke Association 1. The risk of hemorrhagic transformation after rtPA administration in patients with a history of ICH far outweighs the potential benefits of thrombolysis.

The guidelines emphasize that earlier treatment with rtPA is more likely to result in a favorable outcome, but this does not apply to patients with a history of ICH, as the risk of bleeding complications is too high 1. Alternative treatment approaches should be considered for patients with acute ischemic stroke and a history of ICH, such as mechanical thrombectomy if the patient has a large vessel occlusion, or standard medical management including antiplatelet therapy, blood pressure control, and other supportive measures.

Some studies have shown that the presence of early ischemic changes on CT scan is not associated with adverse outcome 1, but this does not change the recommendation for patients with a history of ICH. The timing of the previous ICH does not typically alter this recommendation, as the structural changes in the brain following hemorrhage create a permanent vulnerability to rebleeding.

Key considerations for managing patients with acute ischemic stroke and a history of ICH include:

• Avoiding rtPA therapy due to the high risk of bleeding complications
• Considering alternative treatment approaches, such as mechanical thrombectomy or standard medical management
• Carefully evaluating the patient's individual risk factors and medical history to determine the best course of treatment
• Prioritizing the patient's safety and minimizing the risk of further bleeding complications.

From the Research

Administration of rtPA to Patients with History of Intracerebral Hemorrhage

• The administration of rtPA to patients with a history of intracerebral hemorrhage is a complex issue, with limited direct evidence available 2, 3, 4.
• Studies have shown that the use of rtPA in patients with acute ischemic stroke is safe and effective, but the presence of a history of intracerebral hemorrhage is often considered a contraindication 4, 5.
• However, some studies suggest that the risk of symptomatic intracerebral hemorrhage after rtPA administration may be lower than previously thought, particularly in patients with small-vessel occlusion 6.
• The incidence of symptomatic intracerebral hemorrhage in patients with small-vessel disease administered rtPA was found to be 0.72% (95% CI: 0.12%-1.64%) in one study 6.
• The decision to administer rtPA to a patient with a history of intracerebral hemorrhage should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 2, 3.

Considerations for rtPA Administration

• The time from stroke symptom onset to thrombolysis is crucial, and optimal care of patients with acute stroke should include community education and standardized protocols to guide immediate patient assessment and triage to medical centers with capability for efficient neurologic assessment, brain imaging, drug administration, and specialized post-thrombolysis care 4.
• The use of rtPA in patients with a history of intracerebral hemorrhage requires careful consideration of the potential risks and benefits, and should be guided by evidence-based guidelines and expert opinion 2, 3, 4.