What is the absolute contraindication to thrombolysis in a patient with a history of subdural hemorrhage and acute myocardial infarction?

History of Subdural Hemorrhage is the Absolute Contraindication

In this patient presenting with NSTEMI, the history of subdural hemorrhage represents an absolute contraindication to thrombolytic therapy, regardless of how remote the event or how well-resolved on imaging. The current blood pressure, while elevated, can be managed and does not constitute an absolute contraindication. The history of ischemic stroke and patient age are not absolute contraindications in this context.

Absolute Contraindications to Thrombolysis

The European Society of Cardiology explicitly lists history of hemorrhagic stroke or stroke of unknown origin at any time as an absolute contraindication for thrombolytic therapy 1. While subdural hemorrhage is technically distinct from hemorrhagic stroke, guidelines consistently group intracranial hemorrhage of any type as absolute contraindications 2.

Why Subdural Hemorrhage History Matters

• Any history of intracranial hemorrhage creates permanent risk for recurrent bleeding with thrombolysis, even if imaging shows resolution 1
• The patient's subdural hemorrhage occurred in the context of trauma (fall with head strike), which further increases concern for underlying vascular fragility 3
• Case reports document fatal outcomes when thrombolysis is administered to patients with unrecognized or remote subdural hematomas 3

Why Other Options Are NOT Absolute Contraindications

Current Blood Pressure (186/100 mm Hg)

• Blood pressure >200/120 mm Hg is listed as an absolute contraindication 1
• This patient's BP of 186/100 falls below this threshold
• Refractory hypertension >180 mmHg systolic is only a relative contraindication 1
• The elevated BP can be managed acutely before considering reperfusion therapy

History of Ischemic Stroke

• Ischemic stroke within 6 months is an absolute contraindication 1
• The question states the stroke occurred "TIME_PERIOD prior" with resolution of subdural hemorrhage "TIME_PERIOD ago"
• If this timeframe exceeds 6 months, ischemic stroke history alone would not be absolute
• However, the associated subdural hemorrhage makes this distinction irrelevant 1

Patient Age

• Advanced age is not listed as an absolute contraindication in any guideline 2, 1
• Elderly patients may actually benefit more from primary PCI compared to thrombolysis 2

Transportation Time

• Transfer time is a logistical consideration, not a contraindication 2
• Guidelines support transfer for primary PCI even with delays, particularly in patients with contraindications to thrombolysis 2

Clinical Decision Algorithm for This Patient

This patient should be transferred immediately for primary PCI rather than receiving thrombolytic therapy 2:

1. Recognize the absolute contraindication: History of subdural hemorrhage eliminates thrombolysis as an option 1
2. Control blood pressure: Manage hypertension during transfer to reduce risk of hemorrhagic complications
3. Arrange urgent transfer: Patients with contraindications to thrombolysis have higher mortality and must be transferred for PCI as their only chance for coronary reperfusion 2
4. Initiate antiplatelet therapy: Standard dual antiplatelet therapy is appropriate despite hemorrhage history (remote and resolved)
5. Avoid anticoagulation boluses: Use caution with heparin dosing given hemorrhage history

Critical Pitfalls to Avoid

• Do not assume resolved imaging means resolved risk: Even with normal follow-up imaging, prior intracranial hemorrhage remains an absolute contraindication 1
• Do not delay transfer while attempting blood pressure control: The contraindication is absolute regardless of BP management 2
• Do not consider "relative" risk-benefit analysis: Unlike some contraindications that become relative in life-threatening situations, intracranial hemorrhage history remains absolute even in high-risk scenarios 1

The correct answer is: History of subdural hemorrhage