Absolute Contraindications for Thrombolysis in Ischemic Stroke
The absolute contraindications for thrombolysis in acute ischemic stroke include: any prior intracranial hemorrhage, ischemic stroke within 3 months, intracranial or intraspinal surgery within 2 months, known structural cerebral vascular lesion (e.g., arteriovenous malformation), known malignant intracranial neoplasm, suspected aortic dissection, active bleeding or bleeding diathesis (excluding menses), significant closed-head or facial trauma within 3 months, and severe uncontrolled hypertension unresponsive to emergency therapy. 1
Hemorrhagic and Cerebrovascular Contraindications
The most critical absolute contraindications relate to bleeding risk in the central nervous system:
- Any prior intracranial hemorrhage at any time is an absolute contraindication, as this indicates a permanent vulnerability to recurrent bleeding 1
- Ischemic stroke within the preceding 3 months (some guidelines specify 6 months) represents an absolute contraindication due to increased risk of hemorrhagic transformation 1
- Known structural cerebral vascular lesions including arteriovenous malformations are absolute contraindications 1
- Known malignant intracranial neoplasm (primary or metastatic) is an absolute contraindication 1
- Central nervous system damage or neoplasms constitute absolute contraindications 1
Recent Trauma and Surgery
Timing of recent procedures is critical:
- Intracranial or intraspinal surgery within 2 months is an absolute contraindication 1
- Recent major trauma, surgery, or head injury within the preceding 3 weeks is an absolute contraindication 1
- Significant closed-head or facial trauma within 3 months is an absolute contraindication 1
Important caveat: While recent surgery is listed as an absolute contraindication in guidelines, real-world evidence suggests that thrombolysis may be administered as off-label use after appropriate risk-benefit assessment, particularly when surgery occurred more than 10 days prior, though bleeding risk at the surgical site remains elevated 2
Active Bleeding and Coagulation Disorders
- Active bleeding or bleeding diathesis (excluding menses) is an absolute contraindication 1
- Gastrointestinal bleeding within the last month is an absolute contraindication 1
- Known bleeding disorder is an absolute contraindication 1
Cardiovascular Contraindications
- Suspected aortic dissection is an absolute contraindication due to catastrophic risk of rupture with thrombolysis 1
Blood Pressure Criteria
- Severe uncontrolled hypertension unresponsive to emergency therapy is an absolute contraindication 1
- Specifically, blood pressure should not exceed 185/110 mmHg despite treatment 3
Additional Procedural Contraindications
- Non-compressible punctures within the past 24 hours (e.g., liver biopsy, lumbar puncture) are absolute contraindications 1
Important Clinical Distinctions
The distinction between absolute and relative contraindications can become blurred in life-threatening situations. For example, contraindications considered absolute in acute myocardial infarction may become relative in patients with immediately life-threatening, high-risk pulmonary embolism 1. However, this flexibility does not apply to ischemic stroke, where the risk-benefit ratio is less favorable and absolute contraindications should be strictly observed 1, 4.
Common pitfall: Many original exclusion criteria from clinical trials have proven unnecessarily restrictive in real-world practice 4. However, the absolute contraindications listed above remain firm boundaries that should not be crossed, as they represent situations where the risk of catastrophic hemorrhage clearly outweighs potential benefit 1, 4.
Age alone is not an absolute contraindication - elderly patients who are otherwise eligible should not be denied treatment based solely on advanced age 5, 4