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Table 3. Management of Symptomatic Intracranial Bleeding
Occurring Within 24 Hours After Administration of
IV Alteplase or Tenecteplase for Treatment of AIS
in Adults
Stop alteplase infusion or tenecteplase (if still being pushed).
Emergent CBC, PT (INR), aPTT, fibrinogen level, and type and cross-match.
Emergent nonenhanced head CT if a clinical concern exists.
Cryoprecipitate (includes factor VIII): 10 U infused over 10–30 min to maintain
fibrinogen level of ≥150 mg/dL; as a rule of thumb 10 U of cryoprecipitate increase
fibrinogen level by nearly 50 mg/dL).
Tranexamic acid 1000 mg IV infused over 10 min OR e-aminocaproic acid 4–5 g over
1 h, followed by 1 g IV until bleeding is controlled (peak onset in 3 h).
Potential for benefit in all patients, but particularly when blood products are
contraindicated by patient/family or if cryoprecipitate is not available in a timely manner.
Hematolog y and neurosurgery consultations as necessary.
Supportive therapy, including BP management, ICP, CPP, MAP, temperature, and
glucose control.
Adapted with permission from Sloan et al, Mahaffey et al, Goldstein et al, French et al, Yaghi
et al, Stone et al, and Frontera et al.
AIS indicates acute ischemic stroke; aPTT, activated partial thromboplastin time; BP, blood
pressure; CBC, complete blood count; COR, class of recommendation; CPP, cerebral
perfusion pressure; CT, computed tomography; ICP, intracranial pressure; INR, international
normalized ratio; IV, intravenous; LOE, level of evidence; MAP, mean arterial pressure; and
PT, prothrombin time.
