A 71-year-old right-handed male is brought in by ambulance at 17:50 having suffered a collapse. His wife came home to find him on the floor unable to move his right arm or leg and unable to speak. Her call to the ambulance was logged at 17:30. He has a past medical history of well-controlled hypertension, ischaemic heart disease and atrial fibrillation for which he is on warfarin. He had a hernia repair three months ago and his brother had a ‘bleed in the brain’ at the age of 67. What is the absolute contraindication to thrombolysis in this male?
A. Family history of haemorrhagic stroke
B. History of recent surgery
C. Time of onset
D. Current haemorrhagic stroke
E. Warfarin treatment
Ans: C This man presents with a stroke. It is clinically impossible to tell with certainty whether it is ischaemic or haemorrhagic (D) which is why he needs a CT to differentiate between the two. However, the time of onset is unclear and therefore it is not possible to determine whether he is outside the 3-hour time window for thrombolysis (C). Neither warfarin treatment (E) nor family
history of haemorrhagic stroke (A) are absolute contraindications although they would be taken into consideration. INR should be <1.7. The absolute contraindications for thrombolysis are: onset of symptoms more than 3 hours ago, seizures at presentation, uncontrolled blood pressure (over 180/110), previous intracranial bleed, lumbar puncture in the last week, ischaemic stroke or head injury in the last three months, active bleeding (not menstruation), surgery (B) or major trauma (including CPR) within the last 2 weeks or non-compressible arterial puncture within the last week.