What are the contraindications for thrombolysis?

Contraindications for Thrombolysis

Thrombolytic therapy is contraindicated in patients with active internal bleeding, history of hemorrhagic stroke, recent cranial trauma or neoplasms, blood pressure >200/120 mmHg, and diabetic hemorrhagic retinopathy. 1

Absolute Contraindications

Thrombolytic therapy carries significant risks, particularly bleeding complications. The following conditions are considered absolute contraindications:

• Active internal bleeding 1
• History of hemorrhagic stroke or stroke of unknown origin at any time 1
• Ischemic stroke within the preceding 6 months 1
• Central nervous system damage or neoplasms 1
• Recent major trauma, surgery, or head injury (within preceding 3 weeks) 1
• Gastrointestinal bleeding within the last month 1
• Known active bleeding disorder 1
• Diabetic hemorrhagic retinopathy 1

Relative Contraindications

These conditions increase the risk of complications but may not absolutely prohibit thrombolysis, especially in life-threatening situations:

• Transient ischemic attack in preceding 6 months 1
• Current oral anticoagulant therapy 1
• Pregnancy or within 1 week postpartum 1
• Non-compressible vascular punctures 1
• Traumatic cardiopulmonary resuscitation 1
• Refractory hypertension (systolic blood pressure >180 mmHg) 1
• Advanced liver disease 1
• Infective endocarditis 1
• Active peptic ulcer 1
• Recent (within 10 days) gastrointestinal bleeding 1
• Large thrombus in left atrium or on prosthesis 1
• Known bleeding diathesis 1
• Previous exposure to streptokinase or APSAC (contraindication to reuse any streptokinase-containing agent) 1

Special Considerations

Anticoagulation Status

• International normalized ratio (INR) should be <1.5 2
• Activated partial thromboplastin time (aPTT) should be <50 seconds 2
• Platelet count should be >90×10¹²/L 2

Blood Glucose Levels

• Blood glucose levels should be within 2.7-22 mmol/L 2
• Hyperglycemia (especially >8.4 mmol/L) increases risk of symptomatic intracranial hemorrhage 1

Blood Pressure Management

• Blood pressure should not exceed 185/110 mmHg before thrombolysis 2
• Uncontrolled severe hypertension requires careful management before considering thrombolysis 1

Context-Specific Considerations

It's important to note that in life-threatening situations such as high-risk pulmonary embolism with cardiogenic shock or persistent hypotension, some contraindications that would be considered absolute in other contexts (such as acute myocardial infarction) might become relative 1. The risk-benefit assessment must be individualized based on the severity of the condition and potential alternative treatments.

Risk Factors for Cerebral Hemorrhagic Complications

Factors that increase the risk of intracranial hemorrhage with thrombolysis include:

• Advanced age 3
• Untreated or chronic hypertension 3
• History of cardiac disease 3
• Hyperglycemia 3
• Small body mass 3
• Previous stroke 3
• Longer time to treatment 3
• Increasing severity of neurological deficit 3
• Higher thrombolytic dose 3

Careful patient selection and strict adherence to protocols are essential to minimize the risk of hemorrhagic complications while maximizing the benefits of thrombolytic therapy 3.