In a patient with systemic malignancy presenting with acute ischemic stroke, can intravenous alteplase (tPA) be administered if the platelet count is ≥100 × 10⁹/L, INR ≤1.7, activated partial thromboplastin time is normal, there has been no major surgery or invasive procedure in the past 14 days, no intracranial or intraspinal metastases, and no active internal bleeding?

Systemic Malignancy and Stroke Thrombolysis

Direct Answer

In a patient with systemic malignancy presenting with acute ischemic stroke, intravenous alteplase can be administered if the platelet count is ≥100 × 10⁹/L, INR ≤1.7, aPTT is normal, there has been no major surgery within 14 days, no intracranial or intraspinal metastases are present, and there is no active internal bleeding. 1, 2

Key Principle

Systemic malignancy alone is NOT an absolute contraindication to IV alteplase for acute ischemic stroke. 1, 3, 4 The critical distinction is between patients with specific high-risk features versus those with non-metastatic cancer and normal coagulation parameters.

Absolute Contraindications Related to Malignancy

The following cancer-related conditions absolutely preclude thrombolysis:

• Intracranial metastases - Any metastatic disease to the brain contraindicates alteplase due to hemorrhage risk 1, 4
• Gastrointestinal malignancy with bleeding within 21 days - This represents high bleeding risk and is an absolute contraindication 1
• Active internal bleeding - Any ongoing hemorrhage excludes thrombolysis 1
• Coagulopathy from cancer - Platelet count <100,000/mm³, INR >1.7, PT >15 seconds, or aPTT >40 seconds all contraindicate treatment 1

Conditions That Are NOT Contraindications

Non-metastatic systemic cancer with normal coagulation parameters does not contraindicate alteplase. 2, 4 A 2013 study of 11 patients with current non-metastatic malignancy showed no severe hemorrhagic complications and 73% had favorable outcomes at 3 months when treated with IV thrombolysis. 2

Clinical Decision Algorithm

Step 1: Exclude Absolute Contraindications

• Confirm no intracranial or spinal metastases on non-contrast CT 1, 4
• Verify no GI malignancy with bleeding in past 21 days 1
• Ensure no active internal bleeding 1

Step 2: Verify Coagulation Parameters

• Platelet count ≥100,000/mm³ - Treatment can start before results but must stop if low 1
• INR ≤1.7 and PT ≤15 seconds - Can initiate before results if no recent anticoagulant use 1
• aPTT ≤40 seconds - Must be normal 1

Step 3: Assess Recent Procedures

• No major surgery within 14 days (guideline uses 14 days; some sources reference 3 months for neurosurgery) 5, 1
• No treatment-dose LMWH within 24 hours 1

Step 4: Consider Life Expectancy and Metastatic Status

• Metastatic cancer carries 67% 6-month mortality versus 7-11% for non-metastatic cancer 6
• Gastric/esophageal and pancreatic cancers have particularly poor prognosis (hazard ratios 2.068 and 2.389 for 6-month mortality) 6
• However, life expectancy alone should not exclude treatment if other criteria are met - the immediate stroke disability often outweighs cancer prognosis 3, 4

Evidence Quality and Nuances

The 2019 American Heart Association/American Stroke Association guidelines specifically contraindicate IVT in patients with gastrointestinal or intra-axial (brain) tumors. 4 However, the 2021 European Stroke Organization guidelines do not explicitly list these as contraindications, as recent studies have not proven them to be at higher risk per se. 4

The strongest evidence comes from observational studies showing safety in carefully selected cancer patients. 2, 4 No randomized controlled trials exist for this population, but multiple cohort studies demonstrate that IV thrombolysis is generally safe and effective when specific bleeding risk factors are absent. 3, 2, 4

Critical Pitfalls to Avoid

• Do not withhold thrombolysis based solely on cancer diagnosis - Verify specific contraindications first 2, 4
• Do not assume all cancer patients have coagulopathy - Check actual laboratory values 1, 2
• Do not delay treatment for extensive cancer staging - Focus on immediate bleeding risk factors 3, 4
• Recognize cancer-associated hypercoagulability - These patients often have cryptogenic strokes with multiple lesions, but this does not contraindicate treatment 4

Your Patient Scenario

Based on the specific parameters provided (platelets ≥100 × 10⁹/L, INR ≤1.7, normal aPTT, no surgery within 14 days, no CNS metastases, no active bleeding), this patient CAN receive IV alteplase. 1, 2 The systemic malignancy alone does not contraindicate treatment when these safety parameters are met. 2, 4