What are the contraindications for Tissue Plasminogen Activator (tPA)?

From the Guidelines

Tissue plasminogen activator (tPA) is contraindicated in patients with acute ischemic stroke who have significant head trauma or prior stroke in the previous 3 months, symptoms suggesting subarachnoid hemorrhage, arterial puncture at a noncompressible site in the previous 7 days, history of previous intracranial hemorrhage, intracranial neoplasm, arteriovenous malformation, or aneurysm, recent intracranial or intraspinal surgery, elevated blood pressure, active internal bleeding, acute bleeding diathesis, or certain laboratory abnormalities such as platelet count <100,000/mm³ or INR >1.7 1.

Absolute Contraindications

The following conditions are considered absolute contraindications for tPA administration:

• Significant head trauma or prior stroke in the previous 3 months
• Symptoms suggesting subarachnoid hemorrhage
• Arterial puncture at a noncompressible site in the previous 7 days
• History of previous intracranial hemorrhage
• Intracranial neoplasm, arteriovenous malformation, or aneurysm
• Recent intracranial or intraspinal surgery
• Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
• Active internal bleeding
• Acute bleeding diathesis, including but not limited to platelet count <100,000/mm³
• Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the upper limit of normal
• Current use of anticoagulant with INR >1.7 or PT >15 seconds
• Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests

Relative Contraindications

Relative contraindications for tPA administration include:

• Only minor or rapidly improving stroke symptoms
• Pregnancy
• Seizure at onset with postictal residual neurological impairments
• Major surgery or serious trauma within the previous 14 days
• Recent gastrointestinal or urinary tract hemorrhage within the previous 21 days
• Recent acute myocardial infarction within the previous 3 months
• Blood glucose concentration <50 mg/dL
• CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)

These contraindications are based on the guidelines for the early management of patients with acute ischemic stroke, as outlined in the American Heart Association/American Stroke Association guidelines 1.

From the Research

TPA Contraindications

• Tissue plasminogen activator (tPA) is a thrombolytic agent used to treat acute ischemic stroke and other conditions, but it can cause serious bleeding, including intracranial hemorrhage 2.
• The use of tPA is contraindicated in patients with a high risk of bleeding, such as those with uncontrolled hypertension, recent trauma, or a history of intracranial hemorrhage 3.
• However, a history of cerebral hemorrhage is not an absolute contraindication for thrombolytic therapy, and tPA intravenous thrombolysis may be beneficial for patients with a history of cerebral hemorrhage 3.
• Other potential contraindications for tPA include:
  • Recent use of anticoagulants or antiplatelet agents
  • Presence of an intrauterine device (IUD)
  • Recent surgery or trauma
  • Presence of a bleeding disorder
  • Uncontrolled hypertension
• The risk of symptomatic intracranial hemorrhage (sICH) and early neurologic decline (END) is higher in patients with certain factors, such as older age, history of tobacco use, hyperlipidemia, and presence of an untreated large vessel occlusion 4.
• The timing and predictors of sICH and END can help identify patients at lower risk of neurological deterioration and those suitable for earlier transition to a lower level of care 4.

Special Considerations

• Patients with a history of cerebral hemorrhage should be carefully evaluated before receiving tPA, and the benefits and risks of treatment should be weighed individually 3.
• The use of low-dose tPA (0.5-4 mg) may be effective in treating intraoperative pulmonary thromboembolism during liver transplantation, with a lower risk of bleeding complications 5.
• The management of intracranial hypertension and hemorrhage requires individualized treatment and careful monitoring of blood pressure and other factors 6.