What is the recommended management approach for post-thrombolysis bleeding in a patient with ischemic stroke, including the timing of rechecking coagulation screen and fibrinogen levels after administering fibrinogen and Fresh Frozen Plasma (FFP), and the timing of initiating antiplatelet therapy for underlying stroke?

From the Guidelines

Management of post-thrombolysis bleeding in ischemic stroke patients requires immediate discontinuation of the thrombolytic agent and administration of cryoprecipitate or fibrinogen concentrate along with fresh frozen plasma (FFP) to replenish clotting factors, with recheck of coagulation parameters approximately 15-30 minutes after administration of blood products. When bleeding occurs after thrombolysis, obtain urgent coagulation studies including PT/INR, aPTT, fibrinogen, and complete blood count 1. For significant bleeding, administer cryoprecipitate (10 units) or fibrinogen concentrate (2-4 g) if fibrinogen levels are below 1.5 g/L, along with 2-4 units of FFP to replenish clotting factors. Recheck coagulation parameters approximately 15-30 minutes after administration of blood products, then hourly until stabilized, and every 4-6 hours thereafter until normalized, as suggested by general clinical practice and guidelines for management of bleeding complications 1. Platelet transfusion (1 unit) may be considered if platelet count is low or antiplatelet medications were recently used. Regarding resumption of antiplatelets, wait until neuroimaging confirms bleeding has stabilized, typically 24-72 hours after the bleeding event, as recommended by the American Heart Association/American Stroke Association guidelines 1. Start with a single antiplatelet agent (usually aspirin 81-325 mg daily) if the patient is hemodynamically stable with no evidence of ongoing bleeding. For patients with high thrombotic risk (e.g., recent stent placement), earlier resumption may be considered after multidisciplinary discussion. Dual antiplatelet therapy should generally be delayed for at least 7 days post-bleeding. The timing of anticoagulation resumption for patients with atrial fibrillation should be individualized based on bleeding risk versus stroke risk, typically delayed for 10-14 days after intracranial hemorrhage stabilization. Key considerations in the management of post-thrombolysis bleeding include:

• Prompt recognition and treatment of bleeding complications
• Individualized assessment of the risk of recurrent bleeding versus recurrent ischemic events
• Multidisciplinary discussion and collaboration in the management of complex cases
• Adherence to guidelines and protocols for the management of bleeding complications, as outlined in the American Heart Association/American Stroke Association guidelines 1 and other relevant clinical guidelines 1.

From the Research

Management of Post-Thrombolysis Bleed in Ischemic Stroke Patients

• The management of post-thrombolysis bleed in ischemic stroke patients involves several key considerations, including the use of fibrinogen and fresh frozen plasma (FFP) to correct coagulopathy 2, 3.
• Fibrinogen levels should be monitored closely after thrombolysis, as hypofibrinogenemia is a significant risk factor for intracerebral hemorrhage 2.
• The use of fibrinogen concentrate has been shown to be a safe and effective treatment for post-thrombolysis hemorrhage, with a significant increase in serum fibrinogen levels and a low risk of thromboembolic events 3.

Timing of Coagulation Screen and Fibrinogen Recheck

• The optimal timing for rechecking coagulation screen and fibrinogen levels after giving fibrinogen and FFP is not well established, but it is recommended to monitor these parameters closely after thrombolysis 2, 3.
• Fibrinogen levels should be checked at 2 hours after thrombolysis, and patients with low fibrinogen levels should be considered for fibrinogen supplementation 2.

Use of Antiplatelets for Underlying Stroke

• The use of antiplatelets for underlying stroke is a critical consideration in the management of post-thrombolysis bleed, as antiplatelet therapy can increase the risk of hemorrhage 4, 5.
• Dual antiplatelet therapy with aspirin and clopidogrel is generally indicated for minor noncardioembolic ischemic strokes and high-risk transient ischemic attacks, but should be converted to single antiplatelet therapy after 21 to 90 days 4.
• The decision to start antiplatelet therapy should be individualized based on the patient's risk factors and the presence of any contraindications 4, 5.

Recommended Approach

• The recommended approach to managing post-thrombolysis bleed in ischemic stroke patients involves a multidisciplinary team, including neurologists, intensivists, and hematologists 3, 4.
• Patients should be closely monitored for signs of hemorrhage, and fibrinogen levels should be checked regularly to guide treatment 2, 3.
• The use of fibrinogen concentrate and FFP should be considered in patients with post-thrombolysis hemorrhage, and antiplatelet therapy should be individualized based on the patient's risk factors and clinical presentation 3, 4, 5.