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

Medication Dosing

Tranexamic acid 15mg/kg IV in 250mL over 20 min IV

See Also

• CVA (tPA Criteria)
• CVA (Main)