Can a patient with compensated Child‑Pugh class A cirrhosis and acute ischemic stroke receive intravenous alteplase thrombolysis and/or mechanical thrombectomy if INR ≤ 1.7, platelet count ≥ 50 × 10⁹/L, and no active bleeding?

Thrombolysis and Mechanical Thrombectomy in Child-Pugh A Cirrhosis

Yes, both IV alteplase thrombolysis and mechanical thrombectomy can be safely administered to patients with compensated Child-Pugh A cirrhosis and acute ischemic stroke when INR ≤ 1.7, platelets ≥ 50 × 10⁹/L, and no active bleeding is present. 1

Critical Understanding of INR in Cirrhosis

The elevated INR in cirrhosis does not indicate true anticoagulation or increased bleeding risk during acute stroke treatment. 1 The INR reflects reduced synthesis of both procoagulant and anticoagulant proteins, resulting in a rebalanced but actually pro-thrombotic state rather than "auto-anticoagulation." 1, 2 This is a common pitfall—do not withhold standard acute stroke protocols solely because the patient has cirrhosis or mildly elevated INR. 1

IV Alteplase Thrombolysis Eligibility

Standard Criteria Apply

• Administer IV alteplase (0.9 mg/kg, maximum 90 mg over 60 minutes with 10% bolus) within 4.5 hours of symptom onset or last known well. 3
• Most stroke protocols exclude patients with INR > 1.7, but this threshold does not reliably indicate true anticoagulation in cirrhosis. 1

Platelet Count Requirements

• Proceed safely with thrombolysis when platelets ≥ 50 × 10⁹/L without platelet transfusion. 1
• For platelet counts 40–50 × 10⁹/L, consider providing platelet support during the first 30 days if thrombolysis is administered. 1
• Do not withhold anticoagulation or thrombolysis solely because of moderate thrombocytopenia when platelets exceed 50 × 10⁹/L. 1, 4

Pre-Treatment Assessment

• Only blood glucose assessment must precede IV alteplase initiation. 3
• Obtain electrocardiography, complete blood count, serum electrolytes, creatinine, INR, and troponin, but do not delay reperfusion therapy for these results. 3
• Blood pressure must be lowered below 185/110 mmHg before initiating IV thrombolysis. 3

Mechanical Thrombectomy Eligibility

Indications for Thrombectomy

Proceed with mechanical thrombectomy in Child-Pugh A cirrhosis patients meeting all criteria: 3

• Age ≥ 18 years
• Pre-stroke mRS score 0–1
• Causative occlusion of internal carotid artery or MCA (M1)
• NIHSS score ≥ 6
• ASPECTS ≥ 6
• Treatment initiated (groin puncture) within 6 hours of symptom onset

Extended Time Window (6–24 Hours)

• Mechanical thrombectomy is recommended when advanced imaging (CTP or MRI-DWI) demonstrates sizable mismatch between ischemic core and either clinical deficits or area of hypoperfusion. 3

Combined Approach

• Administer IV thrombolysis even if mechanical thrombectomy is being considered—do not wait to evaluate thrombolysis response before proceeding with catheter angiography. 3
• The technical goal should be reperfusion to modified TICI grade 2b/3. 3

Pre-Treatment Safety Measures Specific to Cirrhosis

Variceal Screening

• Perform upper endoscopy to screen for esophageal varices before starting any anticoagulation for secondary stroke prevention. 1, 2
• Ensure adequate variceal prophylaxis (beta-blockers or band ligation) is in place. 1, 2
• This applies to secondary prevention, not acute thrombolysis/thrombectomy decisions.

Imaging Requirements

• All patients must undergo brain imaging (head CT or brain MRI) without delay upon hospital arrival and before any specific stroke treatment. 3
• For suspected large vessel occlusion, obtain non-invasive angiography (CTA). 3

Common Pitfalls to Avoid

1. Do not assume elevated INR equals contraindication: The hemostatic balance in Child-Pugh A cirrhosis remains pro-thrombotic despite laboratory abnormalities. 1, 2

2. Do not withhold standard protocols: Activate stroke team and proceed with urgent neuroimaging regardless of cirrhosis diagnosis. 1

3. Do not delay for complete laboratory workup: Only glucose must be checked before alteplase; other labs should not delay treatment. 3

4. Do not transfuse platelets unnecessarily: Platelets ≥ 50 × 10⁹/L are sufficient for safe thrombolysis without transfusion. 1

Secondary Prevention Considerations

After acute treatment, Child-Pugh A cirrhosis patients with atrial fibrillation should receive standard-dose DOACs (apixaban, dabigatran, or edoxaban) rather than warfarin, as DOACs demonstrate lower major bleeding (HR 0.63; 95% CI 0.43–0.93) and reduced intracranial hemorrhage (HR 0.49; 95% CI 0.40–0.59). 3, 1 All DOACs can be safely used in Child-Pugh A cirrhosis. 3