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Absolute Contraindications

• CT showing hemorrhage
• History of intracranial hemorrhage
• Intracranial neoplasm or AVM (aneurysm <10mm is generally OK)
• Recent intracranial/spinal surgery (within 3 months)
• Recent serious head trauma (within 3 months)
• Blood glucose <50 mg/dL (treat first, recheck, then reassess)
• Platelet count <100,000 (only if known history of thrombocytopenia — do not wait for results)
• INR >1.7 (only if on warfarin — do not delay for INR if not anticoagulated)
• DOAC within 48h with abnormal drug-specific assay
• Heparin within 48h with elevated PTT
• Aortic arch dissection

Relative Contraindications (use clinical judgment)

• Major surgery or serious trauma (within 14 days)
• GI or urinary bleeding (within 21 days)
• Seizure at onset (treat if true stroke, not if postictal mimic)
• Recent MI (within 3 months)
• Pregnancy (if benefit outweighs risk — discuss with OB)
• Glucose >400 mg/dL (increased hemorrhagic transformation risk)
• Prior stroke within 3 months

NOT Contraindications

• Age >80 years (no longer a contraindication per 2026 guidelines)
• Severe stroke / high NIHSS (higher bleeding risk but also higher benefit)
• Antiplatelet use (aspirin, clopidogrel, DAPT)
• Low NIHSS with disabling deficit (aphasia, hand weakness, hemianopia)
• Unknown INR/platelets if not on anticoagulants — do NOT delay tPA for labs
• Menstruation
• Intracranial aneurysm <10mm
• Diabetic retinopathy (old concern, not supported by evidence)