Which Factor Makes a Patient Ineligible for IV tPA in Acute Ischemic Stroke?
The correct answer is B: GI bleeding 3 months ago makes the patient ineligible for IV recombinant tissue plasminogen activator (rtPA). This falls within the 3-month exclusion window for major bleeding events that represents an absolute contraindication to thrombolytic therapy.
Analysis of Each Option
Option A: BP of 180/105 - Does NOT Make Patient Ineligible
- This blood pressure is actually acceptable for tPA administration. The threshold for eligibility is BP <185/110 mmHg before initiating thrombolysis, and this patient's BP of 180/105 falls below that cutoff 1.
- After tPA administration, BP must be maintained at <180/105 mmHg for at least 24 hours, which means 180/105 is the upper acceptable limit during treatment 1, 2.
- If BP were >185/110 mmHg, it would need to be lowered with IV labetalol or nicardipine before tPA could be given, but the patient would still be eligible once BP is controlled 1.
Option B: GI Bleeding 3 Months Ago - MAKES PATIENT INELIGIBLE ✓
- This is an absolute contraindication. The exclusion criteria from the National Institute of Neurological Disorders and Stroke (NINDS) rtPA trial specify that any significant bleeding event within the previous 3 months excludes patients from thrombolytic therapy 1, 3.
- GI bleeding represents a major hemorrhagic event with high risk of recurrence if thrombolytics are administered, as tPA systemically disrupts hemostasis 3.
- The 3-month window has not yet passed, making this patient ineligible regardless of other factors 4.
Option C: Major Abdominal Surgery a Year Ago - Does NOT Make Patient Ineligible
- Major surgery is only an exclusion criterion if it occurred within the previous 14 days (2 weeks), not one year 5.
- Surgery from one year ago is well beyond the exclusion window and poses no contraindication to tPA administration 5.
- The concern with recent surgery is risk of bleeding at surgical sites, which is negligible after complete healing 5.
Option D: Recent Myocardial Infarction - Context-Dependent
- The term "recent" is vague, but MI within the previous 3 months would be an exclusion criterion based on standard protocols 1.
- However, if "recent" means within days to weeks but not within 3 months, this becomes less clear-cut in the guidelines 1.
- Notably, there are documented cases of acute MI occurring after tPA administration for stroke, suggesting the relationship is complex 6.
- Given the ambiguity of "recent" and that Option B provides a definitive timeframe (exactly 3 months), Option B remains the clearest contraindication.
Key Contraindications to IV tPA
The major absolute contraindications include 1, 3, 4:
- Head trauma or prior stroke within 3 months
- Major surgery within 14 days
- Arterial puncture at non-compressible site within 7 days
- History of intracranial hemorrhage
- Active internal bleeding or major bleeding within 3 months
- BP >185/110 mmHg that cannot be controlled
- Blood glucose <50 mg/dL
- Symptoms suggesting subarachnoid hemorrhage
Clinical Pitfall
A common error is assuming that any cardiovascular comorbidity or moderately elevated BP automatically excludes tPA use. In reality, BP of 180/105 is at the acceptable threshold, and many conditions only matter if they occurred within specific timeframes 1. The 3-month window for major bleeding events is absolute and non-negotiable 1, 3.