Seizure at the onset of stroke – Patients with seizures was excluded from the initial studies of TPA because they made it difficult to assess how much of the neurologic deficit was due to the seizure and how much due to the stroke.
This is important when carrying out a clinical trial, but less important in clinical practice. If you are sure that a stroke has occurred that is causing a disabling deficit, even if the patient has had a seizure, we feel it is appropriate to treat that patient if they qualify by other criteria (particularly no evidence of head trauma with the seizure).
Blood glucose less than 50 mg/dL or greater than 400 mg/dL – If the patient remains symptomatic after a high or low glucose is treated and normalized, they need not be excluded.
Hemorrhagic eye disorder, and other conditions likely to cause disability if bleeding occurs – Recent ocular surgery such as for cataracts, and other minor surgery, are not necessarily contraindications.Judgment is needed. Treatment of a patient with some ocular conditions, such as a recently detached retina, might pose too great a risk of visual loss, especially if the stroke is relatively mild. The best course is to try to reach the specialist consultant and ask for an opinion about bleeding risk.
Myocardial infarction in the prior 6 weeks – Again, judgment should be utilized in interpreting this exclusion. Both the time interval from the MI and the severity of the MI should be taken into consideration. The main risk here is hemorrhagic pericarditis and pericardial tamponade. This would certainly be a risk with a recent transmural MI or open-heart surgery, but a smaller MI, even if recent, would not be considered a contraindication.
Suspected septic embolism or known infective endocarditis.
