In a patient with compensated Child‑Pugh A cirrhosis who had a urinary tract infection one month ago, is that a contraindication to intravenous alteplase (tPA) or mechanical thrombectomy for an acute ischemic stroke with a normal CT brain?

A Resolved Urinary Tract Infection One Month Prior Is NOT a Contraindication to Thrombolysis or Mechanical Thrombectomy

A urinary tract infection that occurred and resolved one month ago in a patient with compensated cirrhosis does not contraindicate either intravenous alteplase or mechanical thrombectomy for acute ischemic stroke. This remote infection is not listed among the absolute or relative contraindications in current American Heart Association/American Stroke Association guidelines 1, 2.

Why This Is Not a Contraindication

Established Absolute Contraindications Do Not Include Remote Infections

The 2018 AHA/ASA guidelines specify absolute contraindications that focus on active bleeding risks, recent major trauma or surgery, and coagulopathy—not resolved infections from weeks prior 1, 2. The key absolute contraindications are:

• Intracranial hemorrhage on CT 1, 2
• History of intracranial hemorrhage at any time 1
• Severe head trauma or intracranial/spinal surgery within 3 months 1
• Gastrointestinal malignancy or bleeding within 21 days 1
• Active coagulopathy (INR >1.7, aPTT >40 seconds, platelets <100,000/mm³) 1, 2
• Symptom onset >4.5 hours 1, 2

The Critical Distinction: Active vs. Resolved Infection

A urinary tract infection treated and resolved one month ago poses no increased bleeding risk for thrombolysis 1. The guidelines exclude patients with active internal bleeding or recent GI bleeding (within 21 days), but do not mention remote, treated infections as contraindications 1, 2.

What You Must Verify in This Patient

Cirrhosis-Related Laboratory Requirements

The cirrhosis itself is not a contraindication, but you must confirm normal coagulation parameters before proceeding 1, 2:

• Platelet count ≥100,000/mm³ 1, 2
• INR ≤1.7 1, 2
• PT ≤15 seconds 1, 2
• aPTT ≤40 seconds 1, 2

You may initiate alteplase before laboratory results return if the patient has no known coagulopathy, but you must stop the infusion immediately if values are abnormal 1, 2.

Exclude Active Bleeding or Varices

• No active gastrointestinal bleeding (hematemesis, melena, hematuria) 1
• No recent variceal bleeding within 21 days 1
• No evidence of hepatic encephalopathy or decompensated cirrhosis that would suggest severe synthetic dysfunction 1

Standard Stroke Eligibility Criteria

• Blood pressure controlled to <185/110 mmHg 2
• CT brain excludes intracranial hemorrhage 2
• Symptom onset ≤4.5 hours (or patient meets extended window criteria with advanced imaging) 1, 2

Mechanical Thrombectomy Considerations

Mechanical thrombectomy has even fewer contraindications than IV alteplase and does not require the same strict coagulation thresholds 3, 4, 5. If the patient has a large vessel occlusion on vascular imaging:

• Proceed with bridging therapy (IV alteplase followed immediately by thrombectomy) if no contraindications to alteplase exist 3, 4
• Proceed directly to thrombectomy if alteplase is contraindicated due to coagulopathy from cirrhosis 3, 5

Bridging therapy improves functional independence (53% vs. 42% with IV alteplase alone) without increasing symptomatic intracranial hemorrhage 4.

Common Pitfalls to Avoid

Do Not Conflate Remote Infection with Active Bleeding Risk

Clinicians sometimes inappropriately withhold thrombolysis due to vague concerns about "infection" or "sepsis risk" when the infection is remote and resolved 6. A treated UTI from one month ago carries zero additional bleeding risk 1.

Do Not Delay Treatment for Unnecessary Workup

If the patient meets eligibility criteria and coagulation parameters are normal (or can be started before results), do not delay alteplase to investigate the resolved UTI 2. Every minute of delay worsens functional outcomes 2.

Cirrhosis Is Not an Automatic Exclusion

Compensated Child-Pugh A cirrhosis with normal coagulation parameters does not preclude thrombolysis 1, 2. The contraindication is abnormal coagulation, not the diagnosis of cirrhosis itself 1.

Algorithmic Approach

1. Confirm stroke diagnosis and time window (≤4.5 hours or extended window criteria) 2
2. Obtain emergent CT brain to exclude hemorrhage 2
3. Check platelet count, INR, PT, aPTT (may start alteplase before results if no known coagulopathy) 1, 2
4. Control blood pressure to <185/110 mmHg 2
5. If all criteria met, administer IV alteplase 0.9 mg/kg (10% bolus, 90% over 60 minutes) 2
6. If large vessel occlusion on CTA/MRA, proceed immediately to mechanical thrombectomy 3, 4
7. Stop alteplase if laboratory results return abnormal (platelets <100,000, INR >1.7, aPTT >40) 1, 2

The resolved UTI from one month ago should not factor into this decision-making process at all 1, 2.