What are the types of bleeds that can occur after thrombolysis (tissue plasminogen activator (tPA)) for stroke?

Types of Bleeding Complications After Thrombolysis for Stroke

Bleeding complications after thrombolysis for acute ischemic stroke are categorized into intracranial hemorrhage (the most serious complication) and systemic hemorrhages (both major and minor extracranial bleeding). 1

Intracranial Hemorrhage (ICH)

ICH is the major bleeding complication associated with thrombolytic therapy, occurring in approximately 6.4% of treated patients in the landmark NINDS trials, defined as any CT-documented hemorrhage temporally related to clinical deterioration within 36 hours of treatment. 1 More recent community-based studies report lower rates. 1

Types of Intracranial Bleeding:

• Symptomatic ICH: Hemorrhage causing neurological deterioration, with mortality rates of 60% or more when it occurs post-thrombolysis 2
• Hemorrhagic transformation: A spectrum ranging from petechial hemorrhages (frequently found in almost all cerebral infarcts naturally) to serious parenchymal hematomas 1
• Subarachnoid hemorrhage: Can occur during endovascular procedures, particularly if the patient recently received thrombolytic therapy 1

Risk Stratification for ICH:

The NIHSS score is the strongest predictor of ICH risk after thrombolysis. Patients with NIHSS >20 have a 17% risk of symptomatic ICH, compared to only 3% in those with NIHSS <10. 1 Other independent risk factors include:

• Age >80 years 1
• Deviation from national treatment protocols 1
• Major early CT changes indicating extensive ischemia 1
• Blood pressure elevation 1
• Blood glucose >200 mg/dL 1
• Advanced age (>65-75 years) and low body weight (<70 kg) 2

Major Systemic Hemorrhages

Major systemic bleeding complications occur in approximately 1.6% of patients treated with IV rtPA and include: 1

• Retroperitoneal hemorrhage: Can occur from arterial access sites during endovascular procedures or spontaneously 1
• Gastrointestinal hemorrhage: Reported 2-3 days after thrombolytic treatment 1
• Genitourinary hemorrhage 1
• Hemopericardium: Particularly in post-cardiac surgery patients 3

Procedural-Related Major Bleeding:

For patients undergoing endovascular thrombectomy:

• Access site hemorrhage: From femoral or radial artery puncture sites 1
• Pseudoaneurysm formation at access sites 1
• Arterial closure device failure leading to bleeding or requiring emergent endarterectomy 1

Minor Bleeding Complications

Minor bleeding complications are common after thrombolytic therapy and include: 1

• Oozing from gums and venipuncture sites 1
• Hematuria 1
• Hemoptysis 1
• Ecchymosis and petechiae: Particularly under blood pressure cuffs 1
• Hematomas: At venipuncture or IV sites 1
• Injection site hemorrhage: Especially in patients with pre-existing thrombocytopenia 4

Special Bleeding Complications

Orolingual Angioedema:

Post-IV thrombolysis orolingual angioedema occurs in 1.3% to 5.1% of patients, can be unilateral (typically contralateral to the affected hemisphere) or bilateral, and risk increases with ACE inhibitor use and frontal/insular strokes. 1 While not strictly a hemorrhagic complication, it requires immediate recognition and treatment with corticosteroids, antihistamines, and possible intubation. 1

Fibrinogen Degradation Coagulopathy:

A decrease ≥200 mg/dL in fibrinogen level 6 hours after thrombolysis is an independent predictor of bleeding risk (OR 4.53), with a population-attributable risk of 39.9% for any major bleeding. 5 This "early fibrinogen degradation coagulopathy" is particularly relevant in patients with less severe strokes (NIHSS ≤16), where it accounts for over 50% of bleeding complications. 5

Clinical Recognition and Monitoring

Hemorrhagic transformation should be suspected with any of the following signs: 1

• Change in level of consciousness
• Elevation of blood pressure
• Deterioration in motor examination
• Onset of new headache
• Nausea and vomiting

Monitoring protocol requires: 1

• Blood pressure checks every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours 1
• Neurological assessments every 15 minutes during infusion, every 30 minutes for 6 hours, then hourly until 24 hours 1

Critical Pitfalls to Avoid

Automatic blood pressure cuffs should be used with caution and checked frequently—if petechiae develop under the cuff, discontinue use immediately. 1 Avoid invasive procedures (arterial punctures, catheter insertions, nasogastric tubes) in the first 24 hours after treatment. 1 Use soft sponges instead of toothbrushes for oral care in the first 24 hours to prevent gingival bleeding. 1

In postoperative patients, surgical site bleeding occurs in 25% of cases (minor in 6%, major in 3%), with significantly higher risk after craniotomy (avoid IAT in intracranial surgery patients when possible). 3