ESO webinar report: Intravenous thrombolysis in patients with relative and absolute contraindications: how far should we go?

The 27th webinar of the European Stroke Organization’s educational series was hosted by Dr. Marieta Peycheva and Dr. Ellis van Etten. With the title “Intravenous thrombolysis in patients with relative and absolute contraindications: how far should we go?”, it features Dr. Thomas Meinel (Inselspital, Bern University Hospital, Switzerland) and Dr. Odysseas Kargiotis (University of Patras, Greece) discussing the boundaries of intravenous thrombolysis (IVT) in some complex situations.

The first part of the discussion regarded patients on direct oral anticoagulants (DOACs), highlighting a case where a patient with high rivaroxaban levels was treated with IVT without complications. Although 2021 ESO guidelines are restrictive regarding DOACs, recent observational data and the 2026 American guidelines suggest that high plasma levels might not always preclude treatment with an individualized risk-benefit analysis. While idarucizumab is a common and safe reversal agent for dabigatran, the use of andexanet alfa as reversal of rivaroxaban/apixaban is not recommended before IVT primarily due to a documented increase in thrombotic events. Ongoing RCTs will clarify the safety and efficacy of IVT in this scenario and results are expected 2028.

The dilemma of minor strokes is another key topic, exemplified by a case where IVT treatment for a mild disabling deficit (left hemiparesis with impaired gait, NIHSS 4) resulted in a fatal brainstem hematoma. Although underpowered and yielding non-statistically significant results, the PRISMS trial demonstrated a trend that alteplase may not benefit minor non-disabling strokes, suggesting that IVT should be avoided in these particular cases. The definition of “disabling” remains inherently subjective and requires careful clinical judgment. However, in patients with large vessel occlusions (LVO) and mild symptoms, some evidence suggests IVT may still be beneficial.

Regarding post-operative patients, guidelines generally suggest waiting 14 days after major surgery, yet the experts emphasize that individual circumstances, such as a non-traumatic spinal puncture, might allow for earlier intervention and communication with the surgeon might be helpful for decision-making.

Patients with a history of stroke were also addressed. Non-randomized data and meta-analyses indicate that previous ischemic strokes generally do not significantly increase haemorrhage risk, though clinical outcomes are often poorer due to pre-existing disabilities. However, strokes occurring within the prior two weeks signal a higher risk for symptomatic haemorrhage, requiring careful consideration of timing and lesion size. In patients with a history of haemorrhagic stroke, the underlying cause is the primary risk predictor. In this context, the two speakers challenge the strict use of microbleed counts: to contraindicate IVT, physicians should rather look for the presence of potential Cerebral Amyloid Angiopathy (CAA)-related symptoms than simply consider exceeding a threshold of ten microbleeds.

For patients with unknown stroke onset times, the consensus is that advanced imaging such as CT perfusion or MRI is mandatory to identify salvageable tissue, as treating without such data beyond standard windows is risky.

In other special scenarios, IVT is considered reasonably safe during pregnancy for disabling deficits but requires caution in cases of recent large myocardial infarctions or long-bone fractures due to systemic bleeding risks. Finally, the presenters stress the importance of individualized care and involving patients and families in decision-making for borderline cases, noting that legal requirements for informed consent vary significantly across different countries.