What is the management approach for a patient suspected of having a hemorrhagic conversion, particularly in terms of imaging, blood pressure control, and potential surgical intervention?

Management of Hemorrhagic Conversion

When hemorrhagic conversion is suspected in acute ischemic stroke, immediately discontinue any ongoing rtPA infusion, obtain emergent CT imaging, send coagulation labs (PT/INR, aPTT, fibrinogen, CBC with platelets, type and cross-match), and prepare to administer 6-8 units of cryoprecipitate and 6-8 units of platelets. 1

Clinical Recognition and Immediate Actions

Suspect hemorrhagic conversion when any of the following occur 1:

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

Stop rtPA infusion immediately if hemorrhage is suspected. 1 Notify the physician immediately and activate your facility's hemorrhage protocol. 1

Imaging Strategy

• Obtain emergent CT scan to confirm hemorrhagic conversion and assess extent of bleeding 1
• For patients with infective endocarditis and suspected hemorrhagic conversion, perform comprehensive neurological imaging including CT angiography or MR angiography to rule out mycotic aneurysms, particularly if intracerebral bleeding is verified 1
• Serial CT imaging is critical - repeat imaging at day 7 and weekly thereafter to monitor stability of hemorrhagic conversion before considering any surgical interventions 1

Laboratory Management

Send the following labs immediately 1:

• Prothrombin time/international normalized ratio (PT/INR)
• Activated partial thromboplastin time (aPTT)
• Fibrinogen level
• Complete blood count with platelets
• Type and cross-match (if not already done)

Reversal of Coagulopathy

Administer 6-8 units of cryoprecipitate (containing factor VIII) and 6-8 units of platelets immediately. 1

For patients on warfarin with elevated INR 1:

• Reverse anticoagulation using vitamin K and fresh-frozen plasma or other hemostatic agents
• This decision must balance the risk of hemorrhagic expansion against the risk of thromboembolism from discontinuing anticoagulation

Discontinue dual antiplatelet therapy (aspirin plus clopidogrel). 1 Aspirin monotherapy may be continued. 1

Avoid intravenous heparin, but subcutaneous heparin or low-molecular-weight heparin is necessary for DVT prophylaxis even with hemorrhagic conversion present on CT. 1

Blood Pressure Management

• Monitor blood pressure intensively in the first 24 hours post-thrombolysis with nurse-to-patient ratio of 1:2 1
• Elevation of blood pressure is a warning sign of hemorrhagic conversion 1
• After 24 hours, if stable, nurse-to-patient ratio may be adjusted to 1:4 1

Monitoring and Supportive Care

Admit to intensive care unit or stroke unit with continuous cardiac telemetry for at least 24 hours after treatment. 1 Nursing staff must be trained in post-thrombolysis care, recognition of bleeding complications, and use of neurological assessment tools including NIHSS. 1

Monitor for both major and minor bleeding complications 1:

• Major: Intracranial hemorrhage (6.4% in NINDS trials), retroperitoneal, genitourinary, gastrointestinal hemorrhages
• Minor: Gum oozing, venipuncture site bleeding, hematuria, hemoptysis

Skin assessment should identify hematomas, ecchymosis, or purpura. 1 Use automatic blood pressure cuffs with caution - check cuff site frequently, rotate every 2 hours, and discontinue if petechiae develop under the cuff. 1

Avoid invasive procedures (arterial punctures, catheter insertion, nasogastric tubes) for 24 hours after thrombolysis. 1 Use soft sponges instead of toothbrushes for oral care in the first 24 hours. 1

Risk Stratification

Higher risk patients for symptomatic intracranial hemorrhage include 1:

• NIHSS score >20 (17% risk vs. 3% for NIHSS <10)
• Age >80 years (independent risk factor)
• Deviations from national guideline treatment protocols

Surgical Considerations

For patients with infective endocarditis and hemorrhagic conversion 1:

• Small hemorrhagic conversions or minimal hemorrhagic transformation: Proceed with cardiac surgery without delay
• Parenchymal hemorrhage: Delay surgery 0-4 weeks depending on size and cardiac urgency; obtain vascular imaging
• Large hemorrhagic conversion: Delay planned cardiac surgery for 3 weeks with weekly CT scans to ensure stability 1

The decision requires multidisciplinary input from infectious disease, cardiology, cardiac surgery, and neurology. 1

Temperature Management

Treat fever >37.5°C aggressively. 1 Development of fever after stroke warrants complete assessment for infectious or drug-induced causes. 1 Normothermia is preferred, though therapeutic hypothermia lacks sufficient evidence. 1

Prognosis

Both hemorrhagic infarction and parenchymal hematoma are independently associated with worse neurological outcomes and lower rates of good functional recovery. 2 Symptomatic hemorrhagic transformation is one of the complications most likely to lead to death in acute ischemic stroke patients. 3