Introduction: Contraindications to IV tPA in acute ischemic stroke (AIS) limits access to a proven medical therapy. A 2015 AHA review assigned Class 3 recommendations (harm) to IV tPA for AIS patients with prior intracranial hemorrhage (pICH), stroke within the last 3 months (SW3), or low platelets (LP) defined as platelets < 100,000. These recommendations, however, were based on sparse literature, notably only 4 AIS patients with pICH and 31 with LP, were reviewed. Our study further investigates the safety of IV tPA in these patient populations.
Methods: We retrospectively reviewed all AIS cases treated with IV tPA at 2 academic centers from 1998-2015 and 2013-2015. Clinical data, including patient demographics, NIHSS, and relative exclusion criteria, was abstracted from each institution’s prospectively maintained stroke database. Neuroimaging and medical chart review was performed by two stroke neurologists.
Results: 324 consecutive AIS patients treated with IV tPA were reviewed. We identified 12 patients who met current Class 3 exclusion criteria (eight pICH, two SW3, two LP). Two patients developed symptomatic hemorrhagic transformation and both had pICH (Table). For comparison, the symptomatic ICH rate in AIS patients receiving IV tPA without relative exclusion criteria was 2.37%, a statistically significant difference (p<0.02, using Fisher’s exact test).
Conclusions: 12 AIS patients with Class 3 exclusion criteria were treated with IV tPA. Our eight reported cases of IV tPA in pICH patients adds substantially to the existing literature. In this study, 25% of patients with pICH developed symptomatic ICH after IV tPA. Although the low number of eligible patients limits interpretation of our findings, continued caution when considering IV tPA for AIS patients with pICH may be warranted. More data is needed to clarify the impact these relative contraindications have on the treatment of AIS.