Absolute Contraindications for Thrombolysis

Core Absolute Contraindications

Hemorrhagic and Cerebrovascular Conditions

• Any history of hemorrhagic stroke or stroke of unknown origin at any time is an absolute contraindication across all clinical contexts 4, 1, 2, 3
• Ischemic stroke within the preceding 3-6 months (3 months for acute stroke protocols, 6 months for other indications like PE or MI) 4, 1, 2, 3
• Known structural cerebral vascular lesions, including arteriovenous malformations and unruptured aneurysms 3
• Known malignant intracranial neoplasm or any central nervous system damage 4, 1, 3

Recent Trauma and Surgery

• Recent major trauma, surgery, or head injury within the preceding 3 weeks 4, 1, 2
• Intracranial or intraspinal surgery within 2 months 3
• Significant closed-head or facial trauma within 3 months 3

Active Bleeding and Coagulation

• Active internal bleeding (excluding menses) 1, 2, 3
• Gastrointestinal bleeding within the last month 4, 1, 2
• Known active bleeding disorder 4, 1, 2

Cardiovascular

• Suspected aortic dissection due to catastrophic risk of rupture 3

Blood Pressure

• Severe uncontrolled hypertension >200/120 mmHg despite emergency treatment 1, 2

Other Specific Contraindications

• Diabetic hemorrhagic retinopathy 1, 2
• Non-compressible vascular punctures within the past 24 hours 3

Relative Contraindications

Cerebrovascular

• Transient ischemic attack within the preceding 6 months 4, 1, 2

Cardiovascular and Hematologic

• Current oral anticoagulant therapy with therapeutic INR (>2-3) 4, 1, 2
• Known bleeding diathesis 1, 2
• Large thrombus in left atrium or on prosthetic valve 1, 2

Blood Pressure (Moderate Elevation)

• Hypertension 180-200/110-120 mmHg (between relative and absolute thresholds) 1, 2

Pregnancy and Recent Delivery

• Pregnancy or within 1 week postpartum 4, 5, 6, 1, 2

Recent Procedures and Trauma

• Recent trauma within 2-4 weeks, including traumatic CPR 1, 2
• Non-compressible vascular punctures 4, 1, 2

Medical Conditions

• Advanced liver disease 4, 1, 2
• Infective endocarditis 4, 1, 2
• Active peptic ulcer disease 4, 1, 2

Drug-Specific

• Prior exposure to streptokinase or APSAC (contraindication to reuse any streptokinase-containing agent, especially within 5 days to 2 years) 1, 2

Critical Context-Dependent Modifications

Life-Threatening Pulmonary Embolism Exception

• In high-risk pulmonary embolism with cardiogenic shock or persistent hypotension, most contraindications become relative rather than absolute 4, 1, 2
• The survival benefit of thrombolysis in hemodynamically unstable PE patients outweighs most bleeding risks 1, 2

Risk Factors That Increase Intracranial Hemorrhage

• Advanced age (>65 years, especially >80 years) 2
• Low body weight (<67-70 kg) - requires dose adjustment for alteplase 2
• Hypertension on admission 2
• Hyperglycemia (especially >8.4 mmol/L or >180 mg/dL) 5, 6, 2

Important Clinical Caveats

Bleeding Risk Data

• Major bleeding occurs in approximately 13% of patients receiving thrombolysis 4
• Intracranial or fatal hemorrhage occurs in 1.8% of patients 4

Special Situations That Are NOT Absolute Contraindications

• Menstruation - can proceed with thrombolysis, though may require transfusion 5, 6
• Cervical artery dissection - appears safe based on >50 reported cases without complications 8, 7
• Cardiac thrombus - not an established contraindication but requires careful evaluation due to potential embolization risk 5, 6, 7
• Recent myocardial infarction - not included as contraindication in European guidelines, though pericarditis is contraindicated 8

Dosing Considerations

• Alteplase dose should be adjusted downward for patients weighing <67 kg to reduce intracranial hemorrhage risk 2
• For acute MI, aspirin 160-325 mg should be given as part of management 2