Including but not limited to…. Thrombolysis Contraindications

An important, but all too often overlooked contraindication to thrombolytics for acute ischemic stroke is known bleeding diathesis including but not limited to current use of oral anticoagulants or an INR > 1.7 or a PT > 15 sec, heparin administration within 48 hours preceding stroke onset and an elevated aPTT at presentation, or platelet count less than 100,000 mm3.
Including but not limited to… Very important, yet easily overlooked.  It also complicates matters, in that, what should or could be included under this contraindication? Platelet dysfunction from HCV, ITP, other oral anticoagulants, hemophilia a or b?
It comes down to risk/benefit. A patient’s risk of ICH secondary to tPA is roughly 8% in the best case (data from NINDS). In real world practice, most likely closer to 13%. Administering tPA to patients with the ‘not limited to’ bleeding diathesis that aren’t explicitly listed could further increase the risk of secondary ICH transformation. All for an improved mRS at 90 days.


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