What is the management for post-tPA (tissue Plasminogen Activator) intracranial hemorrhage?

Management of Post-tPA Intracranial Hemorrhage

Immediate Management

When intracranial hemorrhage (ICH) occurs after tPA administration, immediate discontinuation of the tPA infusion is the first critical step, followed by urgent neuroimaging and implementation of a hemorrhage management protocol. 1

Initial Steps

• Discontinue tPA infusion immediately if hemorrhage is suspected 1
• Obtain emergency brain imaging (CT scan) to confirm hemorrhage 1
• Notify physician immediately 1
• Obtain laboratory work including prothrombin time/international normalized ratio, activated partial thromboplastin time, fibrinogen level, complete blood count with platelets 1
• Type and cross-match blood if not already done 1

Reversal of Fibrinolytic Effect

• Administer 6-8 units of cryoprecipitate containing factor VIII 1
• Administer 6-8 units of platelets 1
• Consider tranexamic acid as an alternative in patients who cannot receive blood products (such as Jehovah's Witnesses) 2

Blood Pressure Management

• Excessive and prolonged hypotension should be avoided 1
• Careful blood pressure control is essential to prevent hematoma expansion 3
• Monitor blood pressure frequently, with goal parameters determined by neurosurgical consultation 1

Intracranial Pressure Management

• For patients with evidence of increased intracranial pressure, consider mannitol administration 4
• Dosage for adults: 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over 30-60 minutes 4
• Mannitol works by increasing plasma osmolarity, inducing movement of intracellular water to extracellular and vascular spaces, thereby reducing intracranial pressure 4

Monitoring and Supportive Care

• Patients should be monitored in an intensive care unit or stroke unit with continuous cardiac telemetry for at least 24 hours after tPA administration 1
• Recent evidence suggests that more than 80% of symptomatic ICH occurs within the first 12 hours after tPA treatment 5
• Nurse-patient ratio should be 1:2 for the first 24 hours; then 1:4 if the patient's condition stabilizes 1
• Perform frequent neurological assessments using standardized stroke scales 1
• Monitor for signs of neurological deterioration: change in level of consciousness, elevation of blood pressure, deterioration in motor examination, onset of new headache, nausea, or vomiting 1

Neurosurgical Consultation

• Obtain immediate neurosurgical consultation to determine if surgical intervention is necessary 3
• Surgical options may include:
  • Conventional craniotomy for hematoma evacuation in selected cases 1
  • Minimally invasive approaches such as stereotactic aspiration in specific situations 1

Prevention of Complications

• Avoid anticoagulants and antiplatelet agents for at least 24 hours after tPA administration 1
• Implement measures to prevent deep vein thrombosis while avoiding pharmacological prophylaxis in the acute period 3
• Monitor for and treat fever aggressively, as it is common after ICH and can worsen outcomes 6
• Avoid prophylactic antiepileptic drugs unless seizures occur 3

Clinical Pitfalls to Avoid

• Delaying reversal of fibrinolytic effect once ICH is confirmed 1
• Failing to monitor for signs of increasing intracranial pressure 4
• Administering anticoagulants or antiplatelet agents within 24 hours of tPA treatment 1
• Using automatic blood pressure cuffs without frequent site checks (can cause hematoma formation) 1
• Performing invasive procedures within 24 hours of tPA administration 1

Prognosis

• Post-tPA ICH is associated with high morbidity and mortality 7
• Early, aggressive treatment in a specialized neurointensive care unit improves outcomes 3
• Most functional and cognitive recovery occurs weeks to months after discharge 6