Special Considerations for Stroke During or After Diagnostic Angiography

For acute stroke onset during or immediately after diagnostic angiography

If a femoral 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 urokinase if the sheath can be accessed and the Interventional Neuroradiology staff is available. If not, consider giving t-PA i.v. 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, t-PA can be reversed with FFP, cryoprecipitate and platelets (see bleeding after t-PA). Vascular Surgery may choose to surgically repair the artery. 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 tPA if still infusing until Brain CT completed and shows no evidence of bleeding.
  • Exclude other possible causes of neurologic worsening or acute hemodynamic instability.
• For confirmed symptomatic hemorrhage on Head CT
  • Consult Neurosurgery for possible intervention.
  • Check STAT labs: CBC, PT, PTT, platelets, fibrinogen and D-dimer.
  • If hypofibrinogenemia present, treat with anitfibrinolytic or cryopreciptate (or both) as follows:
  • Confirmed symptomatic hemorrhage on Head CT: Consult Neurosurgery for possible intervention.
    • Give anti-fibrinolytic: eg, amicar 5gm bolus i.v. over 15-30 min
    • Check STAT labs: CBC, PT, PTT, platelets, fibrinogen and D-dimer.
    • If fibrinogen less than 100 mg/dL, then give Cryoprecipitate 0.15 units/kg rounded to the nearest integer. 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.
  • Institute frequent neurochecks and therapy of acutely elevated ICP, as needed.
  • Additional Options or considerations
    • If platelet dysfunction suspected, give platelets 4 units.
    • If heparin has been administered in the past 3 hours:
      • Discontinue the heparin infusion and order Protamine sulfate. Calculate total amount of heparin received over the preceding 3 hours.
      • If initiated within 30 minutes of last heparin dose: Give 1mg protamine per 100U heparin.
      • If initiated within 30-60 minutes: Give 0.5-0.75 mg protamine per 100U heparin.
      • If initiated within 60-120 minutes: Give 0.375-0.5mg protamine per 100U heparin.
      • If heparin stopped greater than 120 minutes ago: Give 0.25-0.375 mg protamine per 100U heparin.
      • Give by slow IV injection, not to exceed 5mg/min, with total dose not to exceed 50mg.
      • Monitor for signs of anaphylaxis; the risk is higher in diabetics who have received insulin.
      • Follow-up with STAT PTT q1 hour for the next 4 hours, then q4 hours through 12 hours of hospitalization.
    • For uncontrolled, life-threatening bleeding, consider  aminocaproic acid (Amicar) 10 g IV in 250 cc NS IV over 1 hr as a last resort . Note there is a significant risk of pathologic thrombosis with Amicar.
    • 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: Schwamm, Lee, M.D. on behalf of ASQT

Last updated: 12/23/2009