Management of Bleeding Complications after IV Alteplase

Today’s pearl describes potential treatment options for patients that develop an intracranial hemorrhage following the administration of IV alteplase (tPA).

A difficult situation with no great options.

The American Heart Association and American Stroke Association have a joint statement regarding the management of hemorrhagic transformation after intravenous alteplase in acute ischemic stroke. Patient specific treatment should be guided either by your institutional policy or neurology/neurosurgery recommendations.


For patients with acute neurologic change within 24 hours of IV tPA administration, obtain STAT head CT and check STAT labs: CBC, PT, PTT, platelets, fibrinogen and D-dimer. Check blood type and cross-match as appropriate.

  • If IV tPA is still infusing, hold administration until head CT has been performed

Pharmacologic Therapy

For confirmed symptomatic ICH on CT, or for life-threatening systemic hemorrhage, treat with cryoprecipitate or antifibrinolytic (or both) as follows:

  • Give cryoprecipitate 10 units infused over 10–30 min (onset in 1 h, peaks in 12 h). If still bleeding at 1 hr as confirmed by repeat head CT and fibrinogen level still less than 200 mg/dL, repeat cryoprecipitate dose.
  • Give anti-fibrinolytic: aminocaproic acid 5 gram bolus IV over 1 hour OR tranexamic acid 1000 mg IV over 10 minutes

Additional Monitoring

  • Institute frequent neurologic checks and therapy of acutely elevated intracranial pressure, as needed.
  • Discuss potential for operative management with Neurosurgery


Author: Bryan D. Hayes, PharmD

Attending Pharmacist, Emergency Medicine and Toxicology, Massachusetts General Hospital; Assistant Professor of EM, Harvard Medical School

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