Board Review: Intravenous Thrombolytic Therapy 

A 65 y/o male with a past medical history of htn, hld, DM, CAD presents to your emergency department with a new right sided facial droop and right arm weakness.  Family states that the symptoms started acutely approx. 1 hour prior to arrival.  Family also feels that the patient’s speech is slurred.  After thorough examination and workup you suspect an ischemic stroke as the etiology of the symptoms.  Which of the following below would be an absolute contraindication of administering intravenous thrombolytics to this patient?  (scroll down for the answer)?

A) Systolic blood pressure of 170

B) Prior ischemic stroke 2 years prior 

C) Known arteriovenous malformation 

D) Current warfarin treatment with INR of 1.1 

E) Age greater than 60 years old 

The correct answer is C) Known arteriovenous malformation.

Having a known arteriovenous malformation is an absolute contraindication for the administration of intravenous thrombolytic therapy. 

Absolute Contraindications to Intravenous Thrombolytic Therapy for Acute Ischemic Stroke

• Blood pressure > 185/110 mmHg
• Platelet count <100,000/mm3
• Current anticoagulant treatment: warfarin with INR>1.7, heparin with increased aPTT, current use of direct thrombin inhibitor/direct factor Xa inhibitor with evidence of AC effect by labs
• Active or recent internal bleeding (<14 days)
• Any prior hemorrhagic stroke
• Known severe bleeding diathesis 
• Suspected aortic dissection or pericarditis 
• Ischemic stroke within the past 2-6 months
• Intracranial / intraspinal surgery or trauma with the past 2 months
• Intracranial / intraspinal neoplasm, aneurysm, or arteriovenous malformation
• Pregnancy 

Stapczynski, J. Stephan,, and Judith E. Tintinalli. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: McGraw-Hill Education LLC., 2011.