Management of Symptomatic Intracranial Bleeding Occurring Within 24 Hours After Administration of IV Alteplase for Treatment of AIS

• Stop alteplase infusion
• CBC, PT (INR), aPTT, fibrinogen level, and type and cross-match
• Emergent nonenhanced head CT
• Cryoprecipitate (includes factor VIII): 10 U infused over 10–30 min (onset in 1 h, peaks in 12 h); administer additional dose for fibrinogen level of <200 mg/dL
• Tranexamic acid 1000 mg IV infused over 10 min OR ε-aminocaproic acid 4–5 g over 1 h, followed by 1 g IV until bleeding is controlled (peak onset in 3 h)
• Hematology and neurosurgery consultations
• Supportive therapy, including BP management, ICP, CPP, MAP, temperature, and glucose control

Notes

• AIS = acute ischemic stroke
• aPTT = activated partial thromboplastin time
• BP = blood pressure
• CBC = complete blood count
• CPP = cerebral perfusion pressure
• CT = computed tomography
• ICP = intracranial pressure
• INR = international normalized ratio
• IV = intravenous
• LOE = Level of Evidence
• MAP = mean arterial pressure
• PT = prothrombin time

References

• 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke, Stroke. 2018 Mar;49(3):e46-e110 doi: 10.1161/STR.0000000000000158