My original source for this episode was the MDCalc tPA contraindication guidelines which are based off older recommendations (2015). Stroke guidelines and tPA contraindications have changed and are rapidly changing. Always follow the most up to date AHA/ASA guidelines or your institutional protocol, as much of this information may be outdated.


  • tPA is one of the core treatments for acute ischemic stroke
  • The history of tPA is filled with controversy
  • Mechanism
    • Activates plasminogen to plasmin
    • Plasmin breaks down fibrin

Contraindications to tPA

  • Objective contraindications
    • Hypoglycemia
    • Blood pressure (>185/110)
    • Hemorrhagic CVA seen on head CT
  • Other common contraindications
    • Mnemonic: ABCDE
      • A– History of Aneurysm, AVMs (or other intracranial structural problems)
      • B– Actively Bleeding
      • C– IntraCranial injuries (trauma, surgery, or strokes) within last 3 months
      • D– Bleeding Diasthesis (blood thinners, abnormal coagulation panels, clotting disorders)
      • EEndocarditis
  • Relative Contraindications (Discuss with neurology)
    • Minimal or resolving symptoms
    • Recent surgery or major trauma
    • Seizure
    • Recent lumbar puncture
    • Pregnancy
    • Active pericarditis
  • 3-4.5 Hour Contraindication Addons
    • A- Age >80
    • B- Bad Stroke (NIH >25)
    • C- CT shows multilobar stroke
    • D- Bleeding diasthesis (even if coagulation studies normal)
    • E- Ever had old stroke or diabetes

Additional Reading

  • tPA Contraindications for Ischemic Stoke (MDCalc)
  • 2018 Stroke Management Guidelines (AHA/ASA)