What is the immediate management for a patient with ischemic infarct and hemorrhagic conversion?

Immediate Management of Ischemic Infarct with Hemorrhagic Conversion

If hemorrhagic transformation is suspected based on neurological deterioration, immediately discontinue any ongoing rtPA infusion, obtain emergent CT imaging, and prepare to administer cryoprecipitate and platelets while reversing coagulopathy. 1

Recognition and Initial Response

Suspect hemorrhagic transformation when you observe any of the following clinical signs:

• Change in level of consciousness or decreasing mental status 1
• Deterioration in motor examination or worsening neurological symptoms 1
• New onset headache 1
• Nausea and vomiting 1
• Elevation of blood pressure and pulse 1

Stop rtPA immediately if the infusion is still running—do not wait for imaging confirmation if clinical suspicion is high. 1

Emergent Diagnostic Workup

Obtain the following tests simultaneously and urgently:

• Emergent noncontrast CT scan to confirm and characterize the hemorrhage 1
• Complete blood count with platelets 1
• Coagulation parameters: PT, PTT, INR 1
• Fibrinogen levels 1
• Type and screen 1

These laboratory studies guide your reversal strategy and must not delay imaging. 1

Immediate Reversal of Fibrinolysis

The American Heart Association recommends preparing to administer:

• 6 to 8 units of cryoprecipitate (contains factor VIII) to restore fibrinogen levels 1
• 6 to 8 units of platelets 1

While no definitive trial data exist for optimal management, these interventions are standard protocol based on pathophysiologic rationale. 1 A case report suggests tranexamic acid may prevent hematoma expansion, though further studies are needed. 1

Blood Pressure Management

This represents a critical pivot point in management:

• Avoid aggressive blood pressure lowering that was appropriate during ischemic stroke treatment 1
• Markedly elevated blood pressure may increase hemorrhage risk, but hypotension compromises cerebral perfusion 1
• Monitor blood pressure every 15 minutes initially 1
• Target systolic BP to prevent further hemorrhage expansion while maintaining adequate cerebral perfusion pressure 1

The balance is delicate—induced hypertension strategies used for ischemic penumbra are contraindicated once hemorrhagic conversion occurs. 1

Intensive Monitoring Requirements

Transfer or maintain the patient in an intensive care setting with:

• Nurse-patient ratio of 1:2 for at least the first 24 hours 1
• Hourly complete NIHSS assessments for the first 24 hours 1
• Continuous cardiac telemetry 1
• Nursing staff trained in post-thrombolysis hemorrhagic complications 1

Management of Increased Intracranial Pressure

If signs of increased ICP or herniation develop:

• Elevate head of bed 20-30 degrees 2
• Consider osmotherapy with mannitol 0.25-0.5 g/kg IV over 20 minutes, repeating every 6 hours (maximum 2 g/kg) 1, 2
• Hyperventilation to PaCO2 30-35 mmHg as a temporizing measure only 1
• Avoid antihypertensive agents that cause cerebral vasodilation (e.g., sodium nitroprusside) 2

These interventions buy time for definitive treatment but do not improve outcomes alone. 1

Neurosurgical Consultation

Obtain immediate neurosurgical consultation for consideration of:

• Surgical hematoma evacuation based on size, location, and clinical condition 1
• External ventricular drainage if hydrocephalus develops 1, 2
• Decompressive surgery for life-threatening mass effect 1

Large hemorrhages may require evacuation as a lifesaving measure, while smaller hematomas may be tolerated without intervention. 1 Cerebellar hemorrhagic conversion is more likely to become symptomatic and require urgent intervention. 1

Critical Pitfalls to Avoid

• Do not delay intervention waiting for complete laboratory results if clinical deterioration is obvious 1
• Avoid automatic blood pressure cuffs on the same arm as IV access to prevent hematoma formation; check cuff sites frequently and rotate every 2 hours 1
• Do not perform invasive procedures (arterial punctures, catheter insertions, nasogastric tubes) in the first 24 hours after thrombolysis 1
• Use soft sponges instead of toothbrushes for oral care to prevent trauma 1
• Recognize that most symptomatic hemorrhages occur within 12 hours, with the vast majority of fatal hemorrhages in this window 1

Ongoing Surveillance

Continue monitoring for:

• Minor bleeding complications: gum oozing, venipuncture site bleeding, hematuria, hemoptysis 1
• Major bleeding complications: retroperitoneal, genitourinary, gastrointestinal hemorrhages 1
• Skin assessment for hematomas, ecchymosis, or purpura 1
• Development of seizures (treat only if they occur; prophylaxis not recommended) 1, 2

The natural history of ischemic stroke includes petechial hemorrhages in most cases, but symptomatic hemorrhagic transformation requiring intervention occurs in approximately 5-6% of rtPA-treated patients. 1 Your vigilance in the immediate post-conversion period directly impacts mortality and morbidity outcomes.