What is the management of Tissue Plasminogen Activator (tPA)-induced intracranial hemorrhage (ICH)?

Management of Tissue Plasminogen Activator (TNK)-Induced Intracranial Hemorrhage

The management of tissue plasminogen activator (TNK)-induced intracranial hemorrhage requires immediate discontinuation of the thrombolytic agent, rapid reversal of anticoagulation, and aggressive supportive care to limit hematoma expansion and improve survival. 1

Immediate Management Steps

1. Discontinue TNK infusion immediately if it is still running 1

   • Every minute counts in preventing further hemorrhage expansion

2. Obtain urgent neuroimaging

   • Non-contrast head CT to confirm ICH and assess hematoma size, location, and presence of intraventricular extension 1, 2

3. Reverse anticoagulant effect

   • While there are no specific reversal agents for TNK (tissue plasminogen activator), the following measures should be taken:
     • Consider administration of cryoprecipitate (contains fibrinogen and factor VIII) 3
     • Consider antifibrinolytic agents such as aminocaproic acid (Amicar) or tranexamic acid (TXA) to inhibit ongoing fibrinolysis 1, 4
     • Note: There is insufficient evidence to support the routine use of fresh frozen plasma, prothrombin complex concentrates, or platelet transfusions for tPA-associated bleeding 1

4. Aggressive blood pressure management

   • Target systolic blood pressure of 140 mmHg within 1 hour of treatment initiation 1, 2
   • Use intravenous agents such as nicardipine or labetalol for smooth and titratable action 2
   • Avoid rapid decreases of >60 mmHg in the first hour as this may worsen outcomes 1

Critical Care Management

1. Neurocritical care unit admission

   • Patients should be managed in an ICU or dedicated stroke unit with neuroscience expertise 2

2. Intracranial pressure (ICP) monitoring and management

   • Consider ICP monitoring in patients with GCS ≤8, evidence of transtentorial herniation, or significant intraventricular hemorrhage 2
   • Maintain cerebral perfusion pressure at 50-70 mmHg if ICP monitoring is in place 2
   • External ventricular drain may be considered in selected patients at risk of imminent death from intraventricular hemorrhage and hydrocephalus 1
   • Caution: External ventricular drain insertion is a high-risk procedure associated with intra- and post-procedural bleeding in anticoagulated patients 1

3. Seizure management

   • Treat clinical seizures with antiseizure medications 2
   • Treat electrographic seizures found on EEG in patients with altered mental status 2

4. Prevention of venous thromboembolism

   • Apply intermittent pneumatic compression devices as soon as possible 1
   • Note: Graduated compression stockings are not beneficial to reduce DVT or improve outcome 1
   • Consider low-dose subcutaneous low-molecular-weight heparin or unfractionated heparin for prevention of venous thromboembolism only after documentation of cessation of bleeding (typically 1-4 days from onset) 1

Surgical Considerations

1. Cerebellar hemorrhage management

   • Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus should undergo surgical removal of the hemorrhage as soon as possible 2
   • Cerebellar hemorrhages >3 cm or those causing brainstem compression or hydrocephalus should be surgically evacuated 2

2. Ventricular drainage

   • Consider ventricular drainage for hydrocephalus, especially in patients with decreased level of consciousness 2

3. Decompressive craniectomy

   • May be considered in patients with large hemispheric hemorrhages causing significant mass effect and midline shift 1
   • Decision should be based on a risk-benefit discussion between the multidisciplinary medical team and the patient surrogate 1

Important Considerations and Pitfalls

1. Avoid administration of tPA for new ischemic events

   • tPA is contraindicated in patients with recent ICH 1

2. Avoid corticosteroids

   • Corticosteroids should NOT be administered for treatment of elevated ICP in ICH 2

3. Avoid hypotonic solutions and synthetic colloids

   • Use isotonic fluids (0.9% saline) to maintain hydration 2

4. Monitor for complications

   • Myocardial stunning and pulmonary edema related to neurological injury should be anticipated 5
   • Fever is common and should be treated effectively 5

5. Prognostication

   • Most functional and cognitive recovery takes place weeks to months after discharge 5
   • Goals of care impact mortality, with do-not-resuscitate status increasing the predicted mortality for any level of severity of intraparenchymal hemorrhage 5

By following this comprehensive approach to managing TNK-induced intracranial hemorrhage, clinicians can optimize patient outcomes by limiting hematoma expansion, preventing secondary brain injury, and providing appropriate supportive care.