neurology emergency

tPA Contraindications for Ischemic Stroke

Checklist of absolute and relative contraindications to IV alteplase (tPA) for acute ischaemic stroke. Any absolute contraindication = tPA not indicated.

Used in: Stroke & TIA

Within treatment time window (≤3.0h standard; 3.0–4.5h if meeting extended criteria)*

Significant head trauma or prior stroke within 3 months*

Intracranial/intraspinal surgery within 3 months*

History of intracranial haemorrhage*

Uncontrolled hypertension: BP >185/110 mmHg despite treatment*

Symptoms minor and isolated OR rapidly improving*

Coagulopathy (platelet <100k, INR >1.7, aPTT >40, anticoagulants with therapeutic anticoagulation)*

Blood glucose <2.7 mmol/L (<50 mg/dL) or >22.2 mmol/L (>400 mg/dL)*

Major surgery or serious trauma within 14 days*

Score interpretation

None of These Contraindications Present 9

None of the contraindications on this checklist. The list is not exhaustive — also exclude, e.g., haemorrhage or extensive hypodensity on CT, gastrointestinal bleeding within 21 days, treatment-dose low-molecular-weight heparin within 24 h or a DOAC within 48 h, infective endocarditis, aortic arch dissection and intra-axial intracranial neoplasm (AHA/ASA 2019).

→ Confirm with full clinical assessment; activate thrombolysis pathway; dose (adults) = 0.9 mg/kg (max 90 mg), 10% as IV bolus, remainder over 60 min; monitoring post-thrombolysis. Children: use a children's formulary.

Contraindication Present 0–8

One or more potential contraindications identified

→ Neurology assessment required; do NOT administer tPA until contraindications addressed or risk/benefit discussed; consider mechanical thrombectomy if LVO present; assess alteplase vs tenecteplase appropriateness

Interpretation bands for the tPA Contraindications. Apply clinical judgement and local guidance.

References

Powers WJ et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update. Stroke. 2019;50(12):e344–e418.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Drugs

Pathways

Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.

Score interpretation

References

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