Contraindications to Alteplase IV for Acute Stroke in Childhood

History

• Patient last seen well more than 4.5 hours previously.

• Patients in whom time of symptom onset is unknown.

• Prior stroke, major head trauma or intracranial surgery within the last 3 months.

• History of prior intracranial hemorrhage, known AVM, or aneurysm.

• Major surgery or parenchymal biopsy within 10 days.

• GI or GU bleeding within 21 days.

• Patient with neoplasm/malignancy or within one month of completion of treatment for cancer.

• Patients with underlying significant bleeding disorder. (Exception: Patients with mild platelet dysfunction, mild von Willebrand disease or other mild bleeding disorders are NOT excluded.)

• Previously diagnosed with primary angiitis of the central nervous system or secondary arteritis.

Patient factors

• Patient who would decline a blood transfusion if indicated.

• Clinical presentation consistent with acute myocardial infarction or post MI pericarditis that requires evaluation by cardiology before treatment.

• Arterial puncture at noncompressible site or lumbar puncture within last 7 days (relative contraindication). (Exception: Patients who have had cardiac cath via a compressible artery are NOT excluded.)

Etiology

• Stroke due to subacute bacterial endocarditis, sickle cell disease, meningitis, embolism (bone marrow, air or fat), or moyamoya disease.

Exam

• Peristent systolic blood pressure > 15% above the 95th percentile for age while sitting or supine.

• Mild deficit (PenNIHSS < 6) at start of tPA infusion.

• Severe deficit suggesting very larg territory stroke pre-tPA.

• PedNIHSS > 25, regardless of infarct volume seen on neuroimaging.

Imaging

• Symptoms suggestive of subarachnoid hemorrhage even if CT or MRI of head are normal CT with hypodensity/sulcal effacement > 33% of MCA territory or ASPECTS ≤ 7.

• Intracranial cervicocephalic arterial dissection.

Lab data

• Glucose < 50 mg/dL (2.78 mmol/L) or 400 mg/dL (22 mmol/L).

• Bleeding diathesis including Platelets < 100,000; PT > 15 sec (INR > 1.4) or elevated PTT > upper limits of the normal range.