Which of the following is an absolute contraindication to fibrinolytic therapy prior intracranial hemorrhage history of poorly controlled hypertension pregnancy menses?

October 11, 2025 •

4 min read

According to the American Heart Association, a history of any intracranial hemorrhage is a definitive red flag for clinicians. Therefore, to answer which of the following is an absolute contraindication to fibrinolytic therapy prior intracranial hemorrhage history of poorly controlled hypertension pregnancy menses, the correct and most critical answer is prior intracranial hemorrhage, while the others are either relative risks or not contraindications at all.

Quick Summary

This article clarifies that a history of prior intracranial hemorrhage is the absolute contraindication for fibrinolytic therapy, unlike poorly controlled hypertension, pregnancy, or menses, which are typically relative contraindications or not a concern.

Key Points

Prior Intracranial Hemorrhage is Absolute: A history of any intracranial hemorrhage is a definitive and absolute contraindication to fibrinolytic therapy due to the high risk of a recurrent, fatal brain bleed.
Hypertension is Relative: Poorly controlled or severely high blood pressure is typically a relative contraindication. Therapy may proceed after timely and successful blood pressure control.
Pregnancy is Relative: Pregnancy is a relative contraindication due to hemorrhagic risks to both mother and fetus, but may be considered in life-threatening emergencies where benefits outweigh risks.
Menses is Not a Contraindication: Unlike other forms of active bleeding, menstruation is explicitly excluded from the list of absolute contraindications for fibrinolytic therapy.
Know the Difference: Absolute contraindications are non-negotiable reasons to avoid a therapy, whereas relative contraindications require a careful risk-benefit analysis.

Understanding Fibrinolytic Therapy

Fibrinolytic therapy, also known as thrombolytic therapy, is a powerful medical treatment used to dissolve dangerous blood clots that have formed in blood vessels. By administering clot-busting medications such as alteplase or tenecteplase, medical professionals can restore blood flow to critical areas of the body, particularly the heart and brain. This treatment is most commonly used in emergencies to treat conditions like ST-elevation myocardial infarction (STEMI), a severe type of heart attack, and acute ischemic stroke. Its effectiveness is highly dependent on timely administration and a careful assessment of the patient's bleeding risk, as the primary side effect is hemorrhage.

The goal of this therapy is to quickly re-establish perfusion to threatened tissues, which can be life-saving. However, because it works by weakening the body's natural clotting abilities, there is a significant risk of causing uncontrolled bleeding elsewhere, especially in sensitive areas like the brain. This is why a comprehensive screening for contraindications is a mandatory step before administration.

The Crucial Distinction: Absolute vs. Relative Contraindications

Medical conditions and patient histories that prevent a therapy from being used are known as contraindications. For fibrinolytic therapy, these are divided into two critical categories: absolute and relative. Understanding the difference is vital for patient safety.

Absolute Contraindications: These are conditions where the risk of administering the therapy is so high that it is never warranted, regardless of the potential benefits. The danger of a catastrophic complication, such as a fatal intracranial hemorrhage, outweighs any possible positive outcome.
Relative Contraindications: These are conditions that suggest a higher risk of complications, but the decision to proceed with therapy requires a careful, case-by-case evaluation. In life-threatening situations where no alternative is available, the potential benefit may be judged to outweigh the increased risk.

Prior Intracranial Hemorrhage: The Absolute Contraindication

Among the choices provided in the prompt, a prior intracranial hemorrhage is the definitive and absolute contraindication to fibrinolytic therapy. The rationale behind this is the extremely high risk of a recurrent and potentially fatal brain bleed. Fibrinolytic medications work by breaking down clots, and introducing them into a patient with a history of bleeding within the delicate blood vessels of the brain is extremely dangerous. The structural integrity of these vessels may be compromised, and the therapy can cause a rapid and severe re-bleed that could be fatal.

Clinical guidelines from major medical bodies, including the American Heart Association (AHA) and American Stroke Association (ASA), explicitly state that any prior intracranial hemorrhage is an absolute contraindication for thrombolytic treatment. While some recent research has explored the possibility of more lenient criteria in very specific circumstances, the current standard of care and consensus remains that a history of ICH is a firm exclusion criterion.

Other Potential Contraindications and Their Classifications

History of Poorly Controlled Hypertension

Unlike a prior intracranial hemorrhage, a history of poorly controlled hypertension is classified as a relative contraindication. The risk of a hemorrhagic stroke increases significantly in patients with severely high blood pressure. Because of this, it is standard practice to aggressively manage and lower the patient's blood pressure to acceptable levels (typically a systolic blood pressure below 180 mmHg and diastolic below 110 mmHg) before administering fibrinolytic therapy. If blood pressure can be controlled in a timely manner, the therapy can proceed, highlighting its classification as relative rather than absolute.

Pregnancy

Pregnancy is also typically considered a relative contraindication for fibrinolytic therapy, not an absolute one. The decision to treat a pregnant patient with fibrinolytic agents is a complex one, involving a careful balance of risks to both the mother and fetus. The primary concerns are the increased risk of maternal and fetal hemorrhage. However, in life-threatening situations like a massive pulmonary embolism that endangers the mother's life, and when no other treatment options are available, fibrinolytic therapy may be considered. Case studies and reviews have shown that it can be used safely in some circumstances, though it is not a routine procedure.

Menses

Menses, or menstruation, is explicitly not considered an absolute contraindication to fibrinolytic therapy. While active bleeding is an absolute contraindication, medical guidelines make a clear distinction, specifically excluding menstruation. The controlled, non-pathological nature of menstrual bleeding does not pose the same high-risk bleeding complication as other forms of active hemorrhage.

Key Factors Differentiating Contraindications


Factor	Prior Intracranial Hemorrhage	Poorly Controlled Hypertension	Pregnancy	Menses
Contraindication Type	Absolute	Relative	Relative	Not a Contraindication
Primary Risk	Catastrophic brain re-bleed	Increased risk of hemorrhagic stroke if BP is not controlled	Maternal and fetal hemorrhage	Normal physiological process
Decision-Making	Never administered; find alternative therapy	Consider after controlling blood pressure	Case-by-case, risk vs. benefit analysis, especially in emergencies	Proceed with therapy; not a factor
Underlying Reason	Compromised cerebrovascular integrity	High pressure on cerebral vessels	Potential hemorrhagic complications	Non-pathological bleeding

Conclusion

In the evaluation of a patient for fibrinolytic therapy, identifying absolute contraindications is paramount for patient safety. While a history of poorly controlled hypertension and pregnancy warrant careful consideration and a risk-benefit assessment, only a prior intracranial hemorrhage is considered an absolute contraindication that definitively prevents the administration of this powerful clot-busting treatment. Menses is not a contraindication. Thorough patient history and adherence to established guidelines are critical steps in preventing potentially fatal complications and ensuring the appropriate course of action is taken in a medical emergency. For further information and detailed clinical guidelines, consult the American Heart Association website.

Other Common Absolute Contraindications

Known structural cerebral vascular lesion: Conditions like arteriovenous malformations that predispose to bleeding.
Ischemic stroke within 3 months: The exception being acute ischemic stroke treated within 3 hours.
Active bleeding: Any active hemorrhage site, excluding menses.
Suspected aortic dissection: This is a surgical emergency and administering fibrinolysis would be catastrophic.
Recent significant head or facial trauma: This can indicate underlying brain or skull injury.
Recent intracranial or intraspinal surgery: These procedures can leave delicate vessels vulnerable to bleeding.

Frequently Asked Questions

A prior intracranial hemorrhage is an absolute contraindication because it indicates a pre-existing vulnerability in the brain's blood vessels. Administering a powerful clot-dissolving medication could cause a catastrophic, uncontrolled, and often fatal brain bleed.

No, it is a relative contraindication. While severe hypertension at presentation increases hemorrhagic risk, it is possible to manage and lower the patient's blood pressure to a safe level before administering the therapy.

The main risk is hemorrhagic complications for both the mother and the fetus. For this reason, pregnancy is treated as a relative contraindication and therapy is only considered in severe, life-threatening scenarios where alternatives are unavailable.

Menstruation is a normal physiological process and is explicitly excluded from the definition of active bleeding that serves as an absolute contraindication. It does not pose the same level of severe bleeding risk as other hemorrhagic conditions.

An absolute contraindication is a condition where a therapy should never be given because the risks are too high. A relative contraindication is a condition where the therapy can be administered after a careful risk-benefit analysis, especially in life-threatening situations.

It depends on the type and timing of the stroke. A prior intracranial hemorrhage is an absolute contraindication. A prior ischemic stroke is a contraindication if it occurred within the last three months, unless it's a current acute ischemic stroke being treated within the 3-hour window.

Yes, other absolute contraindications include known structural vascular lesions in the brain, suspected aortic dissection, and active internal bleeding.