Emergency physicians may care for patients with symptomatic intracerebral hemorrhage (sICH) following tPA for acute ischemic stroke while the patient is still in the ED or while writing admission orders, for instance. A recent analysis from 10 U.S. stroke centers of 3894 patients treated with IV tPA after symptom onset provides insight about managing such patients. (JAMA Neurol 2015;72:1451; World Neurosurg 2016;88:676.) A total of 128 patients (3.3%) had sICH in this sample, and the in-hospital mortality rate was 52 percent.
The median time from tPA to sICH diagnosis was eight hours. Eighty-six percent (110/128) of patients were diagnosed as having sICH more than two hours after thrombolysis, the time after which standard post-thrombolysis care protocols recommend less frequent neurological assessments. Additional neurological assessments should be performed more frequently to detect sICH earlier, up to 12 hours after tPA administration.
The median time from sICH detection to treatment was long (1.9 hours), allowing for hematoma expansion. Earlier and aggressive treatment might reverse coagulopathy before hematoma expansion occurs. Consider empirical treatment with cryoprecipitate once sICH is diagnosed before obtaining fibrinogen levels. (Most algorithms currently advocate measuring fibrinogen levels before giving cryoprecipitate.)
A decrease in fibrinogen level by more than 200 mg/dL from baseline at six hours after rtPA infusion is associated with sICH. Given that 10 U of cryoprecipitate increases fibrinogen levels by 50-80 mg/dL, this standard dose may result in underdosing and could partially explain the lack of efficacy in preventing hematoma expansion in this study.
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