What is the most important thing to assure before proceeding with a thrombolectomy?

Pre-Thrombectomy Assessment: Critical Exclusion Criteria

Before proceeding with thrombectomy, the most critical thing to confirm is the absence of recent ischemic stroke within the preceding 6 months, as this represents an absolute contraindication to adjunctive thrombolytic therapy and significantly increases hemorrhagic risk. 1

Absolute Contraindications to Verify

When a surgeon plans thrombectomy, you must systematically exclude the following absolute contraindications:

Stroke-Related History

• Hemorrhagic stroke or stroke of unknown origin at any time in the patient's history - this is an absolute contraindication that cannot be overridden 1
• Ischemic stroke within the preceding 6 months - this represents an absolute contraindication to fibrinolytic therapy that may be used adjunctively 1
• Central nervous system damage, tumors, or neoplasms - these conditions preclude safe thrombectomy with thrombolysis 1

Recent Trauma and Surgery

• Major trauma, surgery, or head injury within the preceding 3 weeks - this is an absolute contraindication in most contexts 1
• However, in the context of immediately life-threatening, high-risk pulmonary embolism, recent surgery may become a relative rather than absolute contraindication 1

Active Bleeding Risks

• Gastrointestinal bleeding within the last month - absolute contraindication 1
• Known active bleeding disorder - must be excluded 1

Time-Sensitive Imaging Requirements

For Stroke Thrombectomy (0-6 Hours)

• Noncontrast CT head must be performed immediately to exclude hemorrhage and assess ASPECTS score 2
• CT angiography should be obtained simultaneously to identify large vessel occlusion 2
• ASPECTS score ≥6 and NIHSS ≥6 are required for patient selection 2

For Extended Window (6-24 Hours)

• CT perfusion or DW-MRI with perfusion is mandatory to demonstrate sizable mismatch between ischemic core and hypoperfusion area 2
• Strict adherence to DAWN or DEFUSE-3 criteria is required when selecting patients beyond 6 hours 2

Blood Pressure Management

Pre-Thrombectomy Targets

• For patients potentially eligible for thrombolysis: systolic BP <185 mmHg and diastolic BP <110 mmHg 1
• Refractory hypertension (systolic BP >180 mmHg) represents a relative contraindication to thrombolysis 1

Laboratory Assessment

• aPTT and INR should be obtained but must not delay the procedure 2
• Only blood glucose measurement must precede any IV thrombolytic therapy 2
• For patients on vitamin K antagonists: INR must be <1.7 for safe thrombolysis 3

Common Pitfalls to Avoid

Anticoagulation Status

• Patients on novel oral anticoagulants (NOACs) have minimal safety data for thrombolysis - coagulation parameters should be checked to assess eligibility 3
• Oral anticoagulant therapy represents a relative contraindication requiring careful assessment 1

Timing Errors

• Do not delay imaging to obtain complete stroke history if the patient is within the treatment window 2
• Early transfer to thrombectomy-capable centers is essential for patients at risk, rather than delaying for complete workup 4

Clinical Scale Limitations

• Clinical scales alone (without CTA) have high false-positive rates - 68% of transfers without pre-transfer CTA did not have large vessel occlusion 5
• NIHSS <10 had 88% non-treatment rate after transfer, suggesting the need for vascular imaging before transfer decisions 5

Special Populations Requiring Extra Caution

• Pregnancy or within 1 week postpartum - relative contraindication requiring risk-benefit analysis 1
• Active infective endocarditis - relative contraindication 1
• Advanced liver disease - increases bleeding risk 1
• Thrombocytopenia - must be assessed as it increases procedural risk 1