(Recommendation modified from 2015 IV Alteplase to specify that it does not apply to head trauma. [COR IIb; LOE C-LD]) Recent major surgery Use of IV alteplase in carefully selected patients presenting with AIS who have undergone a major surgery in the preceding 14 d may be considered, but the potential increased risk of surgical-site hemorrhage should be weighed against the anticipated benefits of reduced stroke related neurological deficits. (COR IIb; LOE C-LD) GI and genitourinary bleeding Reported literature details a low bleeding risk with IV alteplase administration in the setting of past GI/genitourinary bleeding. Administration of IV alteplase in this patient population may be reasonable. (COR IIb; LOE C-LD (Note: Alteplase administration within 21 d of a GI bleeding event is not recommended; see Contraindications.) Table 8. Continued (Continued) Menstruation IV alteplase is probably indicated in women who are menstruating who present with AIS and do not have a history of menorrhagia. However, women should be warned that alteplase treatment could increase the degree of menstrual flow. (COR IIa; LOE C-EO) When there is a history of recent or active vaginal bleeding causing clinically significant anemia, then emergency consultation with a gynecologist is probably indicated before a decision about IV alteplase is made. (COR IIa; LOE C-EO) Because the potential benefits of IV alteplase probably outweigh the risks of serious bleeding in patients with recent or active history of menorrhagia without clinically significant anemia or hypotension, IV alteplase administration may be considered. (COR IIb; LOE C-LD) Extracranial cervical dissections IV alteplase in AIS known or suspected to be associated with extracranial cervical arterial dissection is reasonably safe within 4.5 h and probably recommended. 