What are the absolute contraindications to thrombolysis in this patient with acute ischemic stroke?

Absolute Contraindications to Thrombolysis in Acute Ischemic Stroke

Low platelet count, history of stroke, and elevated blood pressure are the absolute contraindications to thrombolysis in this patient with acute ischemic stroke.

Analysis of Patient's Contraindications

This 78-year-old female presents with symptoms of acute ischemic stroke with a large vessel occlusion in the middle cerebral artery. When evaluating eligibility for thrombolysis, several factors must be considered:

Absolute Contraindications Present:

1. Low Platelet Count (<100,000/mm³)

   • The patient's platelet count is 98,000/mm³, which falls below the threshold of 100,000/mm³
   • This is an absolute contraindication according to current guidelines 1

2. Recent Stroke (within past 3 months)

   • The patient had a stroke 2 months ago with residual right-sided deficits
   • Guidelines clearly state that stroke within the previous 3 months is an absolute contraindication 2

3. Elevated Blood Pressure (>185/110 mmHg)

   • The patient's blood pressure is 194/107 mmHg
   • Blood pressure exceeding 185/110 mmHg is an absolute contraindication unless it can be safely reduced 2, 1

Other Factors That Are NOT Absolute Contraindications:

1. Dabigatran Use

   • While the patient was on dabigatran, it was stopped 4 days ago
   • With an INR of 1.2 and normal coagulation studies, this is not an absolute contraindication
   • The effects of dabigatran typically resolve within 48-72 hours in patients with normal renal function 3

2. Advanced Age

   • Age >80 years alone is no longer considered a contraindication to thrombolysis 4
   • Studies have shown benefit of thrombolysis in elderly patients with an adjusted odds ratio of 1.40 (95% CI, 1.14-1.70) 4

3. Breast Cancer History

   • Past history of breast cancer status post mastectomy is not listed as an absolute contraindication in any guidelines
   • Only active internal bleeding or known bleeding diathesis would be contraindications 2

4. Time Window

   • The patient's symptoms began approximately 3 hours before presentation
   • This falls within the 4.5-hour treatment window for IV thrombolysis 1

5. Large Vessel Occlusion

   • The presence of a large vessel occlusion is not a contraindication to thrombolysis
   • In fact, guidelines recommend IV thrombolysis prior to mechanical thrombectomy in eligible patients 1

Clinical Decision Algorithm

1. Evaluate absolute contraindications:

   • Platelet count <100,000/mm³? Yes → Contraindication
   • Stroke within past 3 months? Yes → Contraindication
   • BP >185/110 mmHg? Yes → Contraindication (unless rapidly controlled)

2. Consider relative contraindications:

   • Recent anticoagulant use? No (stopped 4 days ago with normal INR)
   • Advanced age? Not a contraindication
   • Cancer history? Not a contraindication for thrombolysis

Conclusion

The patient has three absolute contraindications to thrombolysis: low platelet count, recent stroke within the past 3 months, and elevated blood pressure. While the elevated blood pressure might potentially be treated to bring it within acceptable range, the other two contraindications cannot be modified. The combination of these factors significantly increases the risk of symptomatic intracranial hemorrhage following thrombolysis 5, making the patient ineligible for this treatment.