New FDA IV tPA contraindications

[Neurologo]

What is your personal view on the changes?
Specifically:

- Would you give tpa to an actively seizing patients?
- to patients with prior history of ICH?
- Would you give it if there is a clinical suspicion but no imaging evidence of SAH? LP is simply not feasible.
- aneurysm is still listed as contraindications but what if it is a small stable one or previously clipped/coiled?

I am not aware of any changes to clinical guideline itself yet.

It would be interesting to see different opinions on these issues.

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[typhoonegator]

- No
- Maybe, if traumatic then definitely yes, BTDT
- No, but needs to be a legit concern
- Yes, BTDT

 

[soulofmpatel]

- Would you give tpa to an actively seizing patients?

no because it is impossible to assess the deficit. If seizure resolved and [for example] obvious M1 syndrome with corroborating radiologic evidence (i.e. Dense MCA sign) and no other contraindication, I would treat.

to patients with prior history of ICH

In old traumatic subdural, yes. With hx of spotaneous subdural-no

Would you give it if there is a clinical suspicion but no imaging evidence of SAH? LP is simply not feasible.

If I suspect SAH then no-but I agree with typhoon that it must be a legit suspicion. Headache is present in about 15% of pts with stroke and is definitely not a contraindication to tPA

aneurysm is still listed as contraindications but what if it is a small stable one or previously clipped/coiled?

I Think both remotely treated and untreated anuerysms are BS contraindications and I would treat both. IV tPA does not cause or increase the risk of aneursym rupture



My general opinion is that the tPA contraindications are ridiculous and arbitrary. Using clinical judgment makes more sense. Just write in your note your justification and explain it to the pt/family. You won't get sued.