Management of Thrombolysis-Associated Symptomatic Intracerebral Hemorrhage

Abstract

Background: Symptomatic intracerebral hemorrhage (sICH) is the most devastating complication of thrombolytic therapy for acute stroke. It is not clear whether patients with sICH continue to bleed after diagnosis, nor has the most appropriate treatment been determined.Methods: We performed a retrospective analysis of our prospectively collected Get With the Guidelines-Stroke database between April 1, 2003, and December 31, 2007. Radiologic images and all procoagulant agents used were reviewed. Multivariable logistic regression was performed to identify factors associated with in-hospital mortality.Results: Of 2362 patients with acute ischemic stroke during the study period, sICH occurred in 19 of the 311 patients (6.1%) who received intravenous tissue plasminogen activator and 2 of the 72 (2.8%) who received intra-arterial thrombolysis. In-hospital mortality was significantly higher in patients with sICH than in those without (15 of 20 [75.0]% vs 56 of 332 [16.9%], PϽ .001). Eleven of 20 patients (55.0%) received therapy for co-

Intravenous Thrombolytic Therapy in Acute Stroke: Problems and Solutions

“…Hemorrhage in the NINDS study was 3.4% with the ECASS criterion and 1.9% with the SITS criterion (90). The mortality of PH type 2 hematomas is more than 50% (92). Expansion and clinical deterioration in follow-up imaging modalities occur in approximately 50% of cases within the first 24 hours (89).…”

“…For this reason, treatment protocols should include antifibrinolytic and cryoprecipitate (or fibrinogen) (93). The treatment modalities and approach to thrombolyticrelated intracerebral hemorrhages vary widely (92).…”

“…It takes around 3 hours for its activity to reach its maximum level. In massive hemorrhages, Amicar ® may also be given at higher doses (IV in 1 hour with 10 g in 250 cc saline) (92,93). Tranexamic acid may be substituted for this agent, which is not found in our country, but there is not enough experience.…”

Management of Postthrombolysis Hemorrhagic and Orolingual Angioedema Complications

“…In the absence of evidence-based guidelines, many academic institutions have developed their own protocols for managing postthrombolysis hemorrhage, and these include the use of fresh frozen plasma (FFP), cryoprecipitate, vitamin K, platelets, and aminocaproic acid. 48,49 Given the optimal approach to management of thrombolysis-associated SICH is not clear, we provide the NINDS trial protocol 1 as a guide with modifications incorporated from Khatri et al 50 and Goldszmidt and Caplan 51 ( Table 2). Most SICH hemorrhages will occur within the first 24 hours after receiving IV r-tPA, with the bulk of fatal hemorrhages occurring within the first 12 hours.…”

Intracerebral hemorrhage secondary to intravenous and endovascular intraarterial revascularization therapies in acute ischemic stroke: an update on risk factors, predictors, and management

“…27 In a retrospective analysis of data from patients with ICH secondary to IV and IA thrombolysis, Goldstein at al. 16 found great variability in treatment protocols, including use of fresh frozen plasma, platelets, cryoprecipitate, phytonadione, and aminocaproic acid. Analysis of treatment records showed that very few patients received the same treatment regimen.…”