Contraindications to Intravenous Alteplase (tPA) in Acute Ischemic Stroke
Intravenous alteplase (IV tPA) is contraindicated when the risk of intracranial bleeding exceeds expected benefit, including multiple specific findings from pretreatment evaluation and laboratory testing. AHA/ASA AIS 2018 guideline slide set [1]
Intracranial imaging or bleeding conditions
- Current intracranial hemorrhage on imaging. AHA/ASA AIS 2018 guideline slide set [1]
- Suspected subarachnoid hemorrhage. AHA/ASA AIS 2018 guideline slide set Activase dosing/administration guide
- Hemorrhage on CT (excludes patients with bleeding as the primary stroke mechanism). AHA/ASA AIS 2018 guideline slide set
Recent cerebrovascular or trauma history
- Ischemic stroke within the previous 3 months. AHA/ASA AIS 2018 guideline slide set
- Head trauma within the previous 3 months. AHA/ASA AIS 2018 guideline slide set
- Intracranial or intraspinal surgery within the previous 3 months. AHA/ASA AIS 2018 guideline slide set
- History of intracranial hemorrhage. AHA/ASA AIS 2018 guideline slide set
Suspected structural or infectious catastrophic causes
- Suspected infectious endocarditis. AHA/ASA AIS 2018 guideline slide set
- Suspected aortic arch dissection. AHA/ASA AIS 2018 guideline slide set
- Intra-axial intracranial tumor. AHA/ASA AIS 2018 guideline slide set
- Extra-axial intracranial tumor. AHA/ASA AIS 2018 guideline slide set
Active bleeding or major recent gastrointestinal bleeding
- GI cancer or GI bleed within 21 days. AHA/ASA AIS 2018 guideline slide set
- Active internal bleeding. Activase dosing/administration guide
Hemostatic abnormalities and recent anticoagulant exposure
- Thrombocytopenia: platelets <100,000/µL. AHA/ASA AIS 2018 guideline slide set
- Elevated coagulation parameters: INR >1.7. AHA/ASA AIS 2018 guideline slide set
- Elevated coagulation parameters: aPTT >40 seconds (or PT >15 seconds per guideline listing). AHA/ASA AIS 2018 guideline slide set
- Therapeutic LMWH within the previous 24 hours. AHA/ASA AIS 2018 guideline slide set
- Direct thrombin inhibitor or factor Xa inhibitor exposure (listed as a contraindication group in the AHA/ASA slide set). AHA/ASA AIS 2018 guideline slide set
- Concurrent IIb/IIIa inhibitors. AHA/ASA AIS 2018 guideline slide set
Stroke mimics and seizure-related presentation
- Seizure at onset. AHA/ASA AIS 2018 guideline slide set
- Stroke mimics (when present as an exclusion category for IV alteplase). AHA/ASA AIS 2018 guideline slide set
Additional AHA/ASA exclusion categories listed under “contraindications (Class III)”
- Cervical dissection (listed as a contraindication category in the AHA/ASA slide set). AHA/ASA AIS 2018 guideline slide set
- Cerebral microbleeds burden (1–20 CMBs) and >10 CMBs are listed in the slide set’s contraindication/additional recommendation categories rather than eligibility. AHA/ASA AIS 2018 guideline slide set
- Large established infarction burden on CT is listed as an exclusion category. AHA/ASA AIS 2018 guideline slide set