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CalculatorstPA Contraindications Checklist — Intravenous Alteplase Eligibility for Acute Ischemic Stroke

NeurologyCriteria

tPA Contraindications Checklist — Intravenous Alteplase Eligibility for Acute Ischemic Stroke

A structured eligibility checklist for intravenous alteplase (IV tPA) administration in acute ischemic stroke (AIS) based on the 2019 AHA/ASA Updated Acute Ischemic Stroke Guidelines and 2023 AHA/ASA updates (tenecteplase considerations). Covers absolute and relative contraindications, patient selection for standard 3-hour and extended 4.5-hour windows, and current FDA-approved and off-label criteria. This checklist reflects the most current evidence-based eligibility criteria with annotation of which historically 'contraindications' are now relative vs. absolute based on post-marketing data.

Parameters

Intracranial hemorrhage on CT (ICH, SAH, SDH) — any intracranial blood on non-contrast CTBlood pressure > 185/110 mmHg AFTER adequate blood pressure treatment attemptsActive internal bleeding (gastrointestinal, urinary, or other internal hemorrhage — NOT including menses)Platelet count < 100,000/µL (thrombocytopenia)INR > 1.7 (current anticoagulation) or PT > 15 secondsHeparin use within 48 hours + elevated aPTT (above upper limit of normal)DOAC use within 48 hours (apixaban, rivaroxaban, edoxaban, dabigatran) unless anti-Xa or direct thrombin levels are normalBlood glucose < 2.7 mmol/L (50 mg/dL) — correct hypoglycemia first (may mimic stroke)Ischemic stroke within the past 3 months (relative to prior large stroke — see relative contraindications for minor stroke)Serious head trauma within the past 3 monthsIntracranial or spinal surgery within the past 3 months

Rapidly improving stroke symptoms (if deficits non-disabling at time of treatment — tPA may not be needed)Seizure at stroke onset (if post-ictal deficits vs. new stroke cannot be differentiated definitively)Major GI or urinary tract hemorrhage within the past 21 daysRecent (past 7 days) arterial puncture at a non-compressible site or lumbar puncturePrior stroke more than 3 months ago — note: no longer absolute contraindication if prior stroke was minor (NIHSS ≤ 5)Acute myocardial infarction (STEMI) in the past 3 months — risk of pericardial hemorrhagePregnancy — relative contraindication; balancing fetal vs. maternal risk with obstetrics consultation recommendedNIHSS > 25 (very severe stroke) — higher sICH risk; discuss with stroke team (tPA still often reasonable)

Age > 80 years AND: (1) history of prior stroke AND (2) diabetes mellitus — combined risk; NOT individually contraindicatedAny anticoagulant use (including warfarin therapeutic INR < 1.7 — note: 3h window, warfarin contraindicated only if INR > 1.7; 4.5h window: any anticoagulant use = additional exclusion)NIHSS > 25 in 4.5-hour window (increased sICH risk, evidence base less robust)

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