tPA Contraindications for Ischemic Stroke

Provides inclusion/exclusion criteria when deciding to use tPA on a patient with acute ischemic stroke.

Eligibility for tPA

Age ≥18

Clinical diagnosis of ischemic stroke causing neurological deficit

Time of symptom onset <4.5 hours

  • See 3-4.5hr warnings below

Absolute Contraindications to tPA

Intracranial hemorrhage on CT

Clinical presentation suggests subarachnoid hemorrhage

Neurologic surgery, serious head trauma, or previous stroke in past 3 months

Uncontrolled hypertension

  • >185 mmHg SBP
  • >110 mmHg DBP

History of intracranial hemorrhage

Seizure at stroke onset

Known arteriovenous malformation, neoplasm, or aneurysm

Active internal bleeding

Suspected/confirmed endocarditis

Known bleeding diathesis

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

Abnormal blood glucose ( <50 or >400 mg/dL)

Relative Contraindications/Warnings to tPA

Only minor or rapidly improving stroke symptoms

Patient has had major surgery or serious trauma excluding head trauma in the previous 14 days

History of gastrointestinal or urinary tract hemorrhage within 21 days

Recent arterial puncture at a noncompressible site

Recent lumbar puncture

Post myocardial infarction pericarditis


Additional Warnings to tPA >3hr Onset

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)


Source: Jauch ED, et al. Guidelines for the early management of patients with acute ischemic stroke: A Guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013; 44: 870-947.