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List contraindications for tPA in STROKE

Hemorrhagic transformation
Previous ICH
Brain cancer
Stroke within 3 mo
Closed head injury within 3 mo
CNS surgery within 2 mo

Plt <100
INR >1.7
Heparin use

Arterial puncture non-compressible
Severe uncontrollable HTN
Glucose <2.8
Active bleeding
Bleeding diathesis


What is the shock index?

Normal is 0.5-0.7
over ~0.8 suggests significant instability and possible shock


What are the basic eligibility criteria for tPA?

Eligibility for tPA
- Age ≥18
- Clinical diagnosis of ischemic stroke causing neurological deficit
- Time of symptom onset <4.5 hours


What are the absolute contraindications to tPA?

- Intracranial hemorrhage on CT
- Clinical presentation suggests subarachnoid hemorrhage
- Neurosurgery, head trauma, or stroke in past 3 months
- Uncontrolled hypertension (>185 mmHg SBP or >110 mmHg DBP)
- History of intracranial hemorrhage
- Known intracranial arteriovenous malformation, neoplasm, or aneurysm
- Active internal bleeding
- Suspected/confirmed endocarditis
- Abnormal blood glucose (<50 mg/dL)
- Known bleeding diathesis

[ie, (1) Platelet count < 100,000; (2) Patient has received heparin within 48 hours and has an elevated aPTT (greater than upper limit of normal for laboratory); (3) Current use of oral anticoagulants (ex: warfarin) and INR >1.7; (4)Current use of direct thrombin inhibitors or direct factor Xa inhibitors]


What are the relative contraindications to tPA?

- Only minor or rapidly improving stroke symptoms
- Major surgery or serious non-head trauma in the previous 14 days
- History of gastrointestinal or urinary tract hemorrhage within 21 days
- Seizure at stroke onset
- Recent arterial puncture at a noncompressible site
- Recent lumbar puncture
- Post myocardial infarction pericarditis
- Pregnancy


What additional cautions are there re tPA?

If <4.5h but >3h:
- Age >80 years
- History of prior stroke and diabetes
- Any active anticoagulant use (even with INR <1.7)
- NIHSS >25
- CT shows multilobar infarction (hypodensity >1/3 cerebral hemisphere)