Contraindications

Name: Contraindications
Creator: NeuroWiki
Published: 2026-02-09T23:21:34+00:00

NeuroWiki

IV Thrombolysis: Contraindications & Special Conditions

This article summarizes absolute and relative contraindications to IV thrombolysis, as well as special clinical scenarios where treatment may be considered.

Contraindications to IV Thrombolysis

Contraindication	Timing / Context	Guideline Statement	COR / LOE
Mild non-disabling stroke 2026	NIHSS 0–5 with non-disabling symptoms	IVT is not recommended; no superiority vs DAPT (PRISMS trial)	Class 3: No Benefit (B-R)
Extensive hypoattenuation on CT	Frank hypodensity / subacute stroke	Not recommended; indicates irreversible injury	Class 3
Acute intracranial hemorrhage	On CT	Contraindicated	Class 3: Harm
Ischemic stroke within prior 3 months	History	Potentially harmful	Class 3
Severe head trauma	Within 3 months	Contraindicated	Class 3: Harm
Intracranial or intraspinal surgery	Within 3 months	Potentially harmful	Class 3
History of intracranial hemorrhage	Any time	Potentially harmful	Class 3
Clinical suspicion of SAH	Presentation	Contraindicated	Class 3: Harm
GI malignancy	History	Potentially harmful	Class 3
GI bleeding	Within 21 days	Potentially harmful	Class 3
Coagulopathy (platelets <100k, INR >1.7, aPTT >40s)	At baseline	Contraindicated	Class 3: Harm
LMWH use (therapeutic dose)	Within 24 hours	Contraindicated	Class 3: Harm
Direct thrombin or factor Xa inhibitors	Within 48h	Not recommended unless cleared by lab or time	Class 3
Concomitant IV abciximab	Within 90 minutes	Contraindicated	Class 3: Harm
Infective endocarditis	Clinical suspicion	Contraindicated	Class 3: Harm
Aortic arch dissection	Known or suspected	Contraindicated	Class 3: Harm
Intra-axial intracranial tumor	Known	Potentially harmful	Class 3
TNK 0.4 mg/kg dose 2026	Any patient	Higher TNK dose is not recommended — no benefit, potential harm	Class 3: No Benefit (A)

Special Clinical Conditions for IV Thrombolysis

Condition	Timing / Context	Guideline Summary	COR / LOE
Cerebral microbleeds — unknown burden 2026	MRI not available	Do NOT delay IVT to obtain MRI to exclude CMBs	Class 1 (B-NR)
Cerebral microbleeds — 1–10 CMBs 2026	Known from prior MRI	IVT is reasonable to achieve better functional outcomes	Class 2a (B-NR)
Cerebral microbleeds — >10 CMBs 2026	Known from prior MRI	Usefulness uncertain; may increase sICH risk. Individualize.	Class 2b (B-NR)
Single or dual antiplatelet therapy 2026	Prior to stroke	IVT is recommended despite increased sICH risk vs no antiplatelet	Class 1 (B-NR)
Coagulation testing 2026	No reason to suspect abnormality	Reasonable NOT to delay IVT for lab results	Class 2a (B-NR)
Age >80	3–4.5h window	IVT is safe and effective, similar to younger patients	Class 1
Diabetes + prior stroke	3–4.5h window	IVT may be reasonable; outcomes similar to 0–3h	Class 2a
Severe stroke (NIHSS >25)	3–4.5h window	Benefit uncertain; decision individualized	Class 2b
Mild but disabling stroke	Within 4.5h	Reasonable to treat if deficits are disabling	Class 2a
Wake-up or unknown onset	DWI-FLAIR mismatch	IVT can be beneficial within 4.5h of symptom recognition	Class 2a (B-R)
Preexisting disability	Any time	May be reasonable; consider goals of care	Class 2b
Early improvement	Any time	Reasonable if residual deficits remain disabling	Class 2a
Seizure at onset	Any time	Reasonable if deficit attributed to stroke, not postictal	Class 2a
Early ischemic changes (mild-moderate)	On NCCT	IVT recommended; does not modify treatment effect	Class 1 (A)
Hypo/hyperglycemia	Initially abnormal	Correct glucose; IVT if deficits persist	Class 1 (C-LD)
Warfarin use	INR ≤1.7	Reasonable to treat	Class 2a
Recent lumbar puncture	Within 7 days	May be considered	Class 2b
Recent arterial puncture	Non-compressible site, <7 days	Uncertain benefit; case-by-case	Class 2b
Recent major trauma (non-head)	<14 days	Reasonable; weigh stroke risk vs. bleeding	Class 2b
Recent major surgery	<14 days	May be considered if benefit outweighs risk	Class 2b
Menstruation	Ongoing or recent	Reasonable in most cases	Class 2a
Extracranial cervical dissection	<4.5h	Probably safe and reasonable	Class 2a
Unruptured aneurysm (<10mm)	Known	Reasonable to treat	Class 2a
Cardiac thrombus / MI history	Recent MI	May be considered; STEMI location influences risk	Class 2b
Pregnancy	Any time	Reasonable if benefit outweighs bleeding risk	Class 2a
Stroke mimics	Presentation	Reasonable to treat; sICH risk is low	Class 2a
Pediatric patients (28 days–18 years) 2026	Within 4.5h, disabling deficits	IVT with alteplase may be considered; safe but efficacy uncertain	Class 2b (C-LD)

🔹 Clinical Pearl: Shared Decision-Making

When patients cannot provide consent (e.g., aphasia) and a legally authorized representative is not immediately available, it is justified to proceed with IVT in an otherwise eligible adult with disabling deficits (Class 1, C-EO) 2026
Discuss potential risks and benefits with competent patients and/or representatives when feasible

References

Prabhakaran S, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke. Stroke. 2026;57:e00–e00.
Powers WJ, et al. 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke. 2019;50:e344–e418.
Demaerschalk BM, et al. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. Stroke. 2016;47:581–641.