Contraindications

Contraindication Timing / Context Guideline Statement
Mild nondisabling stroke Any Time IV alteplase is not recommended for NIHSS 0–5 with nondisabling symptoms
Extensive hypoattenuation on CT Any time Not recommended; indicates irreversible injury
Acute intracranial hemorrhage On CT Contraindicated
Ischemic stroke within prior 3 months History Potentially harmful
Severe head trauma within 3 months History Contraindicated
Intracranial or intraspinal surgery Within 3 months Potentially harmful
History of intracranial hemorrhage Any time Potentially harmful
Clinical suspicion of subarachnoid hemorrhage Presentation Contraindicated
GI malignancy History Potentially harmful
GI bleeding Within 21 days Potentially harmful
Coagulopathy (platelets <100k, INR >1.7, aPTT >40s) At baseline Contraindicated
LMWH use – Therapeutic dose Within 24 hours Contraindicated
Use of direct thrombin or factor Xa inhibitors Within 48h Not recommended unless cleared by lab or time
Concomitant IV abciximab Within 90 minutes Contraindicated
Infective endocarditis Clinical suspicion Contriandicated
Aortic arch dissection Known or suspected Contraindicated
Intra-axial intracranial tumor Known Potentially harmful

Special Clinical Conditions for IV Alteplase Use

Condition Timing / Context Guideline Summary
Age >80 3–4.5h window tPA is safe and effective, similar to younger patients
Diabetes + prior stroke 3–4.5h window tPA may be a reasonable option; similar to 0–3h outcomes
Severe stroke (NIHSS >25) 3–4.5h window Benefit uncertain; decision individualized
Mild but disabling stroke 3–4.5h window Reasonable to treat if disabling deficits are present
Wake-up or unknown onset Recognized <4.5h + MRI mismatch Reasonable to treat if DWI positive, FLAIR negative
Preexisting disability Any time May be reasonable; consider goals of care and prognosis
Early improvement Any time Reasonable if residual deficits remain disabling
Seizure at onset Any time Reasonable if deficit attributed to stroke, not postictal
Low or high blood glucose Initially abnormal Reasonable to treat if glucose normalized before tPA
Warfarin use INR ≤1.7 Reasonable to treat
Recent lumbar puncture Within 7 days May be considered
Recent arterial puncture Non-compressible site, <7 days Uncertain benefit; case-by-case
Recent major trauma <14 days (non-head) Reasonable; weigh stroke risk vs. bleeding
Recent major surgery <14 days May be considered if benefit outweighs risk
Menstruation Ongoing or recent Reasonable in most cases; inform about increased flow
Extracranial cervical dissection <4.5h Probably safe and reasonable
Unruptured aneurysm (<10mm) Known Reasonable to treat
Cardiac thrombus / MI history Recent MI May be considered; STEMI location influences risk
Pregnancy Any time Reasonable if benefit outweighs bleeding risk
Stroke mimics Presentation Reasonable; sICH risk is low