Contraindications of intravenous tissue plasminogen activator (TPA) are based on the original 1995 NINDS trial. Continued use and growing experience has allowed for off-label use. However, there is limited data on TPA safety for subsequent stroke treatment with prior infarct within 3 months. Prior infarct within this timeframe remains a contraindication in the labeling of alteplase. Therefore, this patient population may be excluded from treatment that can potentially offer benefit. In this study, the authors investigated if history of recent infarct conferred a higher hemorrhage risk.
This retrospective study analyzed data from a registry across an 11-year span. Patients were eligible if data about previous stroke and 24-hour outcome were available. Patients were divided into 2 groups: previous stroke and first-ever stroke. Of 13,007 patients treated with TPA, 249 had a prior stroke within 3 months. There were no significant differences in hemorrhage occurrence and 3-month outcome between the two groups.
This study concluded that history of infarct within 3 months did not increase hemorrhage risk after treatment with TPA for a subsequent stroke. However, the relatively low number of patients with history of stroke treated with TPA could represent a selection bias. Furthermore, it may be relevant to determine how many patients were denied treatment of TPA on basis of recent ischemic history but this current study was designed to evaluate solely patients treated with TPA. Within the registry, there was no data available regarding two specific variables that can greatly influence hemorrhage risk: time (in days) from previous infarct and size of infarct. Despite such limitations, withholding TPA based solely on recent infarct less than 3 months may be inappropriate. Further prospective studies can potentially elucidate if there is a specific time and size threshold.