tPA Contraindications for Ischemic Stroke

Checklist-based screen for alteplase eligibility, absolute contraindications, relative warnings, and extended-window exclusions in acute ischemic stroke

INSTRUCTIONS

(1) Time of Onset: You must strictly use the "Last Known Well" (LKW) time. This is the exact time the patient was last observed to be at their neurological baseline, NOT the time the symptoms were discovered (e.g., for wake-up strokes). (2) Differentiate Time Windows: You must accurately identify if the patient falls into the standard 0 to 3-hour window or the extended 3 to 4.5-hour window, as additional strict contraindications apply to the extended window. (3) Blood Pressure: Ensure systolic blood pressure is <= 185 mmHg and diastolic is <= 110 mmHg prior to administration.

Age ≥18 years*

Clinical diagnosis of ischemic stroke causing measurable neurological deficit*

Treatment time window*

≤3 hours from symptom onsetA

>3 to 4.5 hours from symptom onsetB

>4.5 hours from symptom onsetB

Intracranial hemorrhage on CT*

Clinical presentation suggests subarachnoid hemorrhage*

Significant head trauma or prior stroke in previous 3 months*

Arterial puncture at a noncompressible site in previous 7 days*

History of previous intracranial hemorrhage*

Intracranial neoplasm, arteriovenous malformation, or aneurysm*

Recent intracranial or intraspinal surgery*

Elevated blood pressure (systolic >185 mmHg or diastolic >110 mmHg)*

Active internal bleeding*

Acute bleeding diathesis*

Blood glucose <50 mg/dL*

CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)*

Only minor or rapidly improving stroke symptoms*

Pregnancy*

Seizure at onset with residual neurological impairment*

Major surgery or serious trauma within previous 14 days*

Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)*

Recent acute myocardial infarction (within previous 3 months)*

Age >80 years*

History of both prior stroke and diabetes*

Oral anticoagulant use regardless of INR (3–4.5 hour additional exclusion)*

NIHSS >25*