Stroke Treatment with rtPA – Are There any Contraindications?

In the last two decades therapy with recombinant tissue plasminogen activator has been proved the only treatment option in acute ischemic stroke. However, despite unequivocal evidence of patient's benefit from randomized trials and implementation of thrombolytic therapy in national and international guidelines, the transmission into clinical practice is poor. Only a minority of patients receive thrombolysis with severe consequences on public health and economic resources. Besides scientific uncertainties about indications and contraindications for rtPA treatment, educational and organizational conditions have to be established. Educational aspects comprise public information and a referral system to centers with expertise in thrombolysis. Information of and waiting for a family doctor has been shown to delay adequate therapy. If a patient is admitted to the hospital, immediate clinical diagnosis and cerebral imaging has to be performed to avoid a delay in therapy. Several questions about thrombolysis have to be answered. Can the time window of 3 hours after symptoms onset in some patients be widened to six or more hours? What is the role of modern stroke imaging, can MRI enlarge the indication for therapy with rtPA? Can patients with cerebral microangiopathy and older patients be treated? Should patients be treated despite incomplete symptom recovery? Does sopor after stroke increase the bleeding risk? Do patients with a visible infarction more than 1/3 of the territory of the middle cerebral artery on the first CT scan profit from rtPA? What are the indications for intraarterial thrombolysis and who is better treated intravenously? Although thrombolysis has to be carefully indicated, more patients might receive this treatment.