What is the contraindication to administering tissue plasminogen activator (tPA) in a patient with a history of ischemic stroke?

From the Guidelines

The major contraindication to administering tissue plasminogen activator (tPA) in this patient is a prior stroke within the last 3 months. According to the guidelines for the early management of patients with acute ischemic stroke, a prior stroke in the previous 3 months is a significant contraindication to tPA therapy 1. This is because patients with recent ischemic strokes have a higher risk of hemorrhagic transformation when given tPA, due to the compromised blood vessels in the damaged brain tissue.

The patient's current presentation, including fever, hypertension, and warfarin use, are also important considerations. However, the patient's INR of 1.6 is below the threshold of 1.7, which is a contraindication to tPA therapy 1. The patient's blood pressure, although elevated, is not above the threshold of systolic >185 mm Hg or diastolic >110 mm Hg, which is a contraindication to tPA therapy 1.

Key points to consider in this patient's management include:

• Prior stroke within the last 3 months is a contraindication to tPA therapy
• INR < 1.7 is not a contraindication to tPA therapy
• Blood pressure should be carefully monitored and managed to minimize the risk of hemorrhagic transformation
• The patient's overall clinical presentation and eligibility criteria should be carefully evaluated before making a decision about tPA therapy.

In this case, the prior stroke within the last 3 months is the most significant contraindication to tPA therapy, and alternative management strategies should be considered 1.

From the FDA Drug Label

CONTRAINDICATIONS Cathflo Activase should not be administered to patients with known hypersensitivity to Alteplase or any component of the formulation (see DESCRIPTION). The FDA drug label does not answer the question.

From the Research

Contraindications for Tissue Plasminogen Activator (tPA) Administration

The patient's history and current condition need to be carefully evaluated to determine the contraindications for tPA administration. Based on the provided studies, the following points are relevant:

• Recent Ischemic Stroke: A study published in the Journal of clinical medicine 2 found that thrombolysis after recent ischemic stroke does not increase the risk for hemorrhagic transformation or worsen the functional outcome in otherwise healthy mice. However, this study does not directly address the human context, and clinical guidelines typically advise caution.
• Warfarin Use and INR Levels: Research published in the Journal of stroke and cerebrovascular diseases 3 suggests that administration of IV r-tPA for AIS in warfarin-treated patients with subtherapeutic INR <1.7 does not increase the risk of symptomatic intracranial hemorrhage. The patient's INR of 1.6 falls within this range.
• Hypertension and Fever: While hypertension > 140/90 mm Hg and fever > 38℃ are considerations in the management of stroke patients, the provided studies do not specifically address these as contraindications for tPA in the context of recent stroke or warfarin use.

Specific Contraindications

Given the patient's history of ischemic stroke 2 months ago, the key consideration is:

• Ischemic Stroke < 3 months ago: This is a critical factor. Clinical guidelines and studies 2, 4, 5 emphasize the importance of timing and the risk associated with recent ischemic events. The patient's recent stroke is a significant consideration for tPA administration.

In summary, the primary contraindication to the administration of tissue plasminogen activator in this patient, based on the provided information and studies, is:

• Ischemic stroke < 3 months ago, as this condition increases the risk of hemorrhagic transformation and other complications, although the direct evidence from the studies provided does not conclusively state this as a contraindication, it is a critical consideration in clinical practice 2, 4, 5.