Exclusion criteria to be eligible for intravenous thrombolysis in acute ischemic stroke

Q: Which of the following is NOT an exclusion criterion to be eligible for intravenous thrombolysis in acute ischemic stroke? (select one)

A) Intracranial or intraspinal surgery within last 3 months

B) Symptoms suggestive of subarachnoid hemorrhage

C) Active internal bleeding

D) Large (≥10 mm), untreated, unruptured intracranial aneurysm

E) Persistent systolic blood pressure ≥185 mmHg

Answer: D

Exclusion criteria to be eligible for intravenous thrombolysis in acute ischemic stroke is usually divided into four headings:

• Patient history
• Clinical
• Hematologic
• Head CT

Patient history

• Ischemic stroke or severe head trauma in the previous three months
• Previous intracranial hemorrhage
• Intra-axial intracranial neoplasm
• Gastrointestinal malignancy
• Gastrointestinal hemorrhage in the previous 21 days
• Intracranial or intraspinal surgery within the prior three months

Clinical

• Symptoms suggestive of subarachnoid hemorrhage
• Persistent blood pressure elevation (systolic ≥185 mmHg or diastolic ≥110 mmHg)
• Active internal bleeding
• Presentation consistent with infective endocarditis
• Stroke is known or suspected to be associated with aortic arch dissection
• Acute bleeding diathesis, including but not limited to conditions defined under 'Hematologic'

Hematologic

• Platelet count <100,000/mm3
• Current anticoagulant use with an INR >1.7 or PT >15 seconds or aPTT >40 seconds
• Therapeutic doses of low molecular weight heparin received within 24 hours (eg, to treat VTE and ACS); this exclusion does not apply to prophylactic doses (eg, to prevent VTE)
• Current use (i.e., last dose within 48 hours in a patient with normal renal function) of a direct thrombin inhibitor or direct factor Xa inhibitor with evidence of anticoagulant effect by laboratory tests such as aPTT, INR, ECT, TT, or appropriate factor Xa activity assays

  

Head CT

• Evidence of hemorrhage
• Extensive regions of obvious hypodensity consistent with irreversible injury

  

Some conditions may be relative contraindications or warnings or need close monitoring, which includes

• Only minor and isolated neurologic signs or rapidly improving symptoms
• Serum glucose <50 mg/dL (<2.8 mmol/L)
• Serious trauma in the previous 14 days
• Major surgery in the previous 14 days
• History of gastrointestinal bleeding (remote) or genitourinary bleeding
• Seizure at the onset of stroke with postictal neurologic impairments
• Pregnancy
• Arterial puncture at a noncompressible site in the previous seven days
• Large (≥10 mm), untreated, unruptured intracranial aneurysm
• Untreated intracranial vascular malformation

  

There are additional warnings for treatment from 3 to 4.5 hours from symptom onset.

• Age >80 years
• Oral anticoagulant use, regardless of INR
• Severe stroke (NIHSS score >25)
• Combination of both previous ischemic stroke and diabetes mellitus

 

  

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References:

  

1. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359:1317.

2. Del Zoppo GJ, Saver JL, Jauch EC, et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator. A science advisory from the American Heart Association/American Stroke Association. Stroke 2009; 40:2945.

3. Re-examining Acute Eligibility for Thrombolysis (TREAT) Task Force:, Levine SR, Khatri P, et al. Review, historical context, and clarifications of the NINDS rt-PA stroke trials exclusion criteria: Part 1: rapidly improving stroke symptoms. Stroke 2013; 44:2500.

4. Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2016; 47:581.

5. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With 

Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344.