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Special Considerations and Management of Bleeding Complications After IV t-PA

For acute stroke onset during or immediately after diagnostic angiography

May occur in the context of cardiac, neuro or peripheral interventional diagnostic angiography or treatment. If a femoral, radial or brachial arterial sheath is still in place, DO NOT REMOVE IT. The sheath should remain sutured in place while t-PA is given. Consider intra-arterial therapy if the sheath can be accessed and the Neuroendovascular staff agree that it is warranted. If not, consider giving t-PA IV at full dose 0.9 mg/kg. In all cases, leave the sheath in place and check STAT PTT. Observe the groin site closely and follow Hct and vital signs for evidence of acute blood loss. If a hematoma forms or there is evidence of blood loss, notify Vascular Surgery and apply pressure until hemostasis is achieved. If bleeding continues, see (see bleeding after t-PA). If no bleeding occurs, the sheath can be removed after 24 hours. If heparin cannot be held for sheath removal, Vascular Surgery will surgically close the vessel in the operating room.

For acute stroke onset days or weeks after transfemoral diagnostic angiography

If a femoral arterial sheath has been pulled within 2 weeks, carefully weigh the risk of bleeding against the anticipated benefit of t-PA therapy. If t-PA is given, notify Vascular Surgery prior to drug administration. Then observe the groin site closely and follow Hct and vital signs for evidence of acute blood loss. (Occult blood loss may occur into the retroperitoneum.) If any hematoma forms or there is evidence of acute blood loss, notify Vascular Surgery and apply direct pressure until hemostasis is achieved. If occult blood loss occurs, obtain an abdominal CT to look for retroperitoneal hematoma. If bleeding continues, t-PA can be reversed with FFP, cryoprecipitate, and platelets (see bleeding after t-PA).

Bleeding after t-PA

  • For suspected symptomatic hemorrhage after t-PA or other plasminogen activator has been given:
    • Hold administration of IV t-PA if still infusing until head CT or alternative imaging (if hemorrhage is suspected elsewhere) has been completed and shows no evidence of bleeding.
    • Exclude other possible causes of neurologic worsening or acute hemodynamic instability.
    • Check STAT labs: CBC, PT, PTT, platelets, fibrinogen and D-dimer.
    • Send blood bank sample for type and screen, cross-match and hold packed red cells appropriate to the hemorrhage volume, location, and associated symptoms
    • For uncontrolled, life-threatening bleeding, consider aminocaproic acid (Amicar) 10 g IV in 250 cc NS IV over 1 hr (note: there is a significant risk of pathologic thrombosis with Amicar).
    • For systemic hemorrhage, compress any compressible sites of bleeding, and consult appropriate additional services to consider mechanically occluding arterial or venous sources of medically uncontrollable bleeding.
  • For confirmed symptomatic hemorrhage on Head CT
    • Check STAT labs: CBC, PT, PTT, platelets, fibrinogen and D-dimer.
    • If hypofibrinogenemia present, treat with anitfibrinolytic or cryopreciptate (or both) as follows:
      • Give anti-fibrinolytic: eg, amicar 5 gram bolus i.v. over 15- 30 min
      • If fibrinogen less than 100 mg/dL, then give cryoprecipitate 10 units. If still bleeding at 1 hr and fibrinogen level still less than 100 mg/dL, repeat cryoprecipitate dose.
      • Institute frequent neurochecks and therapy of acutely elevated ICP, as needed.
    • Additional Options or considerations
      1. If patient has a known platelet disorder, give 6 units platelets.
      2. For uncontrolled, life-threatening bleeding, consider aminocaproic acid (Amicar) 10 grams IV in 250 cc NS IV over 1 hr as a last resort . Note there is a significant risk of pathologic thrombosis with Amicar.
      3. Serious systemic hemorrhage should be treated in a similar manner. Manually compress and compressible sites of bleeding, and consult appropriate additional services to consider mechanically occluding arterial or venous sources of medically uncontrollable bleeding

Authoring Information

Reviewed/Approved by: Rost, Natalia, M.D., M.P.H. on behalf of ASQT

Last updated: 1/16/2015

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