Post-tPA Hemorrhage in CVA

Background

Consider post-tPA ICH if patient develops:
- Decreased LOC
- Worsening neurologic exam
- Increased weakness
- New headache
- Sudden rise in BP
May also have GI bleed, mucosal bleeding

Management

Immediately Stop tPA, even on suspicion of post-tPA hemorrhage
STAT Head CT
If no bleeding: resume tPA
If post-tPA ICH present
- Obtain baseline labs: CBC, D-dimer, type and screen, fibrinogen. Check INR 15 minutes after FFP administration (see below) and platelets 15 min after platelet administration (see below)
- Administer cryoprecipitate 10 units for fibrinogen replacement
  - If fibrinogen returns > 150, discontinue, if < 150, recheck in 1 hr and if still low administer additional 20 units
- Administer FFP 20 ml/kg
  - If INR > 1.4, give additional 20 ml/kg)
- Administer 2-5 packs platelets
  - If platelets <100,000, give additional PRN to achieve Plt > 100,000
- STAT neurosurgery consult
- Consider TXA 15 mg/kg IV in 250 ml x 20 min if ongoing hemorrhage after above measures

See Also

References

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