31
Table 6. Other Situations Wherein Thrombolysis is Deemed
to be Considered
Conditions that are relative contraindications
Pre-existing
disability
The benefits vs risks of offering IV thrombolysis in patients with
pre-existing disability and/or frailty remain uncertain. Treatment
should be determined on an individual basis.
DOAC exposure In patients with disabling symptoms and recent DOAC exposure
(<48 hours) who are within the window for alteplase/tenecteplase,
the safety of IV thrombolysis is unknown. Emerging but limited
observational data suggest IV thrombolysis may be considered after
a thorough benefit vs risk analysis on an individual basis. Benefit
vs risk assessments should include considering the timing of the
latest DOAC administration, renal function, stroke severity, and
availability of endovascular thrombectomy as well as availability
of DOAC reversal agents and DOAC-specific anti-factor Xa/
thrombin time assays acknowledging the potential for delay in
thrombolysis and potential increased thrombotic risk. All aspects
of DOAC management (timing, reversal agent use, assay results),
should be recorded carefully to facilitate ongoing safety analyses.
Definitive clinical trials are needed to establish the safety of IV
thrombolysis in DOAC patients.
Ischemic stroke
w/in 3 months
Use of IV thrombolysis in patients presenting with AIS who have
had a prior ischemic stroke within 3 months may be at increased
risk of intracranial hemorrhage. Potential increased risk as a result
of the timing and size of the stroke should be weighed against the
benefits of offering IV thrombolysis in an individualized manner
in such patients.
Prior ICH IV thrombolysis administration in patients who have a history of
ICH may increase the risk of symptomatic hemorrhage. Patients
with known amyloid angiopathy may be considered as having
higher risk than patients with ICH due to modifiable conditions
(eg, HTN, coagulopathy). IV thrombolysis may have greater
treatment benefit than risk in these latter patients. Treatment
should be determined on an individual basis.
Recent major
non-CNS trauma
(between 14 days
and 3 months)
Patients with recent major trauma between 14 days and 3
months of their AIS may be at increased risk of harm and serious
systemic hemorrhage requiring transfusion from IV thrombolysis.
Individual consideration of risk vs benefit, involved areas, and
consultation with surgical experts are appropriate.
(cont'd)
