From the Research
A recent hemorrhagic stroke is generally considered a contraindication for thrombolysis in ischemic stroke, but the most recent and highest quality evidence suggests that this contraindication may not be absolute. Patients with a history of intracranial hemorrhage are typically not candidates for tissue plasminogen activator (tPA) due to the increased risk of bleeding 1. However, a study from 2024 found that intravenous thrombolysis despite previous direct oral anticoagulant treatment was not associated with an increased risk of bleeding, and may even be safe in certain cases 2. Another study from 2022 suggested that thrombolysis after recent ischemic stroke does not increase the risk for hemorrhagic transformation or worsen the functional outcome in otherwise healthy mice, but hyperglycemia may lead to neurological deterioration after tPA treatment 3.
Key Considerations
- The risk of bleeding is a major concern when considering thrombolysis in patients with a recent hemorrhagic stroke
- Alternative management strategies, such as mechanical thrombectomy, may be considered for patients who cannot receive thrombolytics due to this contraindication
- The most recent evidence suggests that the contraindication for thrombolysis in patients with a recent hemorrhagic stroke may not be absolute, and individual cases should be evaluated on a case-by-case basis
- The decision to administer thrombolysis in a patient with a recent hemorrhagic stroke should be made with caution, taking into account the individual patient's risk factors and the potential benefits and risks of treatment 4, 5.
Management Strategies
- Mechanical thrombectomy may be considered for patients with a large vessel occlusion and meets other criteria for this procedure
- Alternative thrombolytic strategies, such as tenecteplase, may be considered in certain cases 5
- The use of direct oral anticoagulants and reversal agents may also be considered in certain cases 2