What is the treatment for a patient with a brain bleed after intravenous thrombolysis (IVT) for acute ischemic stroke?

Management of Post-IVT Brain Hemorrhage

Immediately stop the alteplase infusion, obtain emergent non-contrast head CT, send coagulation labs (CBC, PT/INR, aPTT, fibrinogen, type and cross-match), and administer cryoprecipitate 10 units plus tranexamic acid 1000 mg IV or aminocaproic acid 4-5 g IV to reverse the coagulopathy. 1

Immediate Actions

Stop the infusion immediately if the patient develops severe headache, acute hypertension, nausea, vomiting, or neurological worsening during or after alteplase administration. 1

Laboratory Evaluation

• Send stat labs: Complete blood count, PT (INR), aPTT, fibrinogen level, and type and cross-match 1
• Obtain emergent non-contrast head CT to confirm and characterize the hemorrhage 1

Pharmacologic Reversal (Class IIb, LOE C-EO)

First-Line Hemostatic Agents

Cryoprecipitate (contains factor VIII): Administer 10 units infused over 10-30 minutes; onset occurs in 1 hour and peaks at 12 hours. Give additional doses if fibrinogen level remains <200 mg/dL. 1

Antifibrinolytic therapy (choose one):

• Tranexamic acid: 1000 mg IV infused over 10 minutes (peak onset in 3 hours) 1
• OR ε-aminocaproic acid: 4-5 g IV over 1 hour, followed by 1 g IV infusion until bleeding is controlled (peak onset in 3 hours) 1

Supportive Management

Blood Pressure Control

• Maintain strict BP control: Target systolic BP ≤180 mm Hg and diastolic BP ≤105 mm Hg 1
• Increase monitoring frequency if BP exceeds these thresholds 1

Additional Supportive Measures

• Manage intracranial pressure (ICP) and maintain adequate cerebral perfusion pressure (CPP) and mean arterial pressure (MAP) 1
• Control temperature and glucose levels 1
• Avoid placing nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters unless absolutely necessary 1

Specialist Consultation

Obtain immediate consultations:

• Hematology for coagulopathy management 1
• Neurosurgery for potential surgical intervention 1

Critical Monitoring

Neurological assessments:

• Every 15 minutes during the first 2 hours after hemorrhage detection 1
• Every 30 minutes for the next 6 hours 1
• Hourly until 24 hours post-event 1

Important Caveats

The evidence for reversal strategies is limited (Class IIb, LOE C-EO), meaning these recommendations are based on expert opinion and observational data rather than randomized trials. 1 However, the high mortality rate (75% in-hospital mortality for symptomatic ICH after thrombolysis) 2 justifies aggressive intervention despite limited evidence.

Continued bleeding occurs in approximately 40% of patients with symptomatic ICH after thrombolysis who have follow-up imaging, suggesting a critical window for intervention. 2 This underscores the importance of rapid reversal of coagulopathy.

Do not delay treatment to obtain all laboratory results if clinical suspicion is high—initiate reversal measures while awaiting confirmation. 1

Avoid antiplatelet and anticoagulant therapy for at least 24 hours after the hemorrhage, and only restart after repeat imaging confirms stability and clinical improvement. 1