Article Text

Intravenous thrombolysis in acute ischaemic stroke: from trial exclusion criteria to clinical contraindications. An international Delphi study


Objective: Several studies indicate that only a small proportion of patients with acute ischaemic stroke are treated with intravenous thrombolysis. Indications and contraindications for this treatment are usually based on the inclusion and exclusion criteria of randomised clinical trials. The trial context of these criteria hampers implementation in real life settings. We therefore aimed to obtain specialist opinion in a Delphi consensus on these contraindications.

Methods: We used the Delphi approach on an international group of specialists in the field of thrombolysis. Inclusion and exclusion criteria were reworded into 18 quantitatively phrased propositions. Feedback consisted of the median score, interquartile range and the panellist’s own score in the previous round. For each item, we defined consensus as the achievement of an interdecile range within two prespecified clinically relevant units.

Results: Thirty-one specialists participated in the first round and 30 completed all three rounds. Consensus was reached on 12 of the 18 propositions: previous ischaemic stroke, head trauma and gastrointestinal tract bleeding should not have taken place earlier than 1.5 months, 2 months and 14 days, respectively; the severity of the neurological deficit is defined as a National Institutes of Health Stroke Scale (NIHSS) score of 2–3 or more, and blood pressure level should not be >185/110 mmHg; platelet count should be >90×1012/l, glucose levels 2.7–22 mmol/l, international normalised ratio <1.5 and activated partial thromboplastin time <50 s. No consensus was reached on propositions concerning the stroke onset to treatment time, patient’s age, recent medical procedures, spontaneous improvement rate and blood pressure treatment.

Conclusions: We present specialists’ opinion on contraindications for intravenous thrombolysis in ischaemic stroke. The results of this study may be relevant for routine clinical practice as they may help to increase the number of treated patients.

  • INR, international normalised ratio
  • NIHSS, National Institutes of Health Stroke Scale
  • NINDS, National Institute of Neurological Disorders and Stroke
  • rtPA, recombinant tissue plasminogen activator

Statistics from


  • Published Online First 1 March 2007

  • Funding: This study is part of a larger project that includes a clustered randomised trial to implement thrombolysis in acute stroke in Dutch hospitals, funded by the Netherlands Organisation for Health Research and Development (ZON-MW, grant No 945-14-217). ZON-MW is the national health council appointed by the Ministry of Health (VWS) and the Netherlands Organization for Scientific Research (NWO) to promote quality and innovation in the field of health research and care.

  • Competing interests: None declared.

Request permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.