What is an absolute contraindication to using thrombolytic therapy in the treatment of an acute ischemic stroke?

Absolute Contraindication to Thrombolytic Therapy in Acute Ischemic Stroke

Currently taking rivaroxaban is an absolute contraindication to thrombolytic therapy in acute ischemic stroke. Active use of direct oral anticoagulants (DOACs) like rivaroxaban within the last 48 hours represents a standard contraindication to IV thrombolysis due to the significantly elevated bleeding risk 1.

Analysis of Each Option

Currently Taking Rivaroxaban (ABSOLUTE CONTRAINDICATION)

• Standard guidelines consider recent DOAC use (within 48 hours) an absolute contraindication to IV thrombolysis 1
• The American College of Chest Physicians guidelines do not explicitly address novel oral anticoagulants in their 2012 recommendations, as these agents were newer at that time 2
• Recent European Stroke Organization guidelines suggest thrombolysis may be considered only if anti-factor Xa activity is <0.5 × 10³ IU/L or drug-calibrated concentrations are <25 μg/L, but this requires specialized testing not routinely available 3
• Without immediate drug level measurement capability, rivaroxaban use within 48 hours remains an absolute contraindication 3

Cardiac Rhythm is Atrial Fibrillation (NOT a contraindication)

• Atrial fibrillation itself is not a contraindication to thrombolysis 2
• In fact, patients with atrial fibrillation and acute ischemic stroke are eligible for IV r-tPA if they meet other criteria 1
• The presence of atrial fibrillation influences long-term secondary prevention (requiring oral anticoagulation) but does not preclude acute thrombolytic therapy 2, 1

Pregnancy (RELATIVE contraindication, not absolute)

• Pregnancy is traditionally considered a relative contraindication rather than an absolute contraindication to thrombolysis
• The guidelines provided do not explicitly list pregnancy as an absolute contraindication 2
• Risk-benefit assessment must be individualized, but pregnancy does not automatically exclude thrombolysis in life-threatening situations

Systolic Blood Pressure of 175 mm Hg (NOT a contraindication at this level)

• A systolic blood pressure of 175 mm Hg is below the threshold that would contraindicate thrombolysis 2
• Standard protocols typically require blood pressure to be reduced to <185/110 mm Hg before administering IV r-tPA
• At 175 mm Hg systolic, this patient's blood pressure is within acceptable limits for thrombolysis administration
• The guidelines emphasize bleeding risk increases with uncontrolled hypertension, but 175 mm Hg systolic does not represent an absolute contraindication 2

Critical Imaging Contraindication

• The presence of intracranial hemorrhage on CT or MRI is an absolute contraindication to IV thrombolytic therapy (excluding microbleeds) 2
• Imaging must be completed within 45 minutes of emergency department arrival to exclude hemorrhage before thrombolysis 2

Common Pitfalls

• Do not assume all anticoagulation represents the same risk: warfarin with INR ≤1.7 may allow thrombolysis, but recent DOAC use (rivaroxaban, apixaban) within 48 hours is contraindicated without specialized drug level testing 3, 4
• Experimental data suggests rivaroxaban may have less hemorrhagic risk than warfarin, but this does not change current clinical contraindications 5
• Case reports of successful thrombolysis despite rivaroxaban use exist, but these represent exceptions requiring specialized testing and should not guide standard practice 6, 7