Management of Post-IVT Brain Hemorrhage

Immediate Actions

The American Heart Association recommends immediately stopping the alteplase infusion if the patient develops severe headache, acute hypertension, nausea, vomiting, or neurological worsening during or after alteplase administration 1, 2
The American Heart Association suggests obtaining emergent non-contrast head CT to confirm and characterize the hemorrhage, and sending stat labs, including complete blood count, PT, aPTT, fibrinogen level, and type and cross-match 1, 2

The American College of Cardiology recommends administering cryoprecipitate 10 units infused over 10-30 minutes, with additional doses if fibrinogen level remains low, to reverse coagulopathy (Class IIb, LOE C-EO) 1, 2
The American College of Cardiology suggests using antifibrinolytic therapy, such as tranexamic acid 1000 mg IV or ε-aminocaproic acid 4-5 g IV, to reverse coagulopathy (Class IIb, LOE C-EO) 1, 2

The American Heart Association recommends maintaining strict blood pressure control, targeting systolic BP ≤180 mm Hg and diastolic BP ≤105 mm Hg, and increasing monitoring frequency if BP exceeds these thresholds 1, 2
The American Heart Association suggests managing intracranial pressure, maintaining adequate cerebral perfusion pressure and mean arterial pressure, and controlling temperature and glucose levels 1, 2

The American Heart Association recommends obtaining immediate consultations with hematology for coagulopathy management and neurosurgery for potential surgical intervention 1, 2

The American Heart Association suggests performing neurological assessments every 15 minutes during the first 2 hours after hemorrhage detection, every 30 minutes for the next 6 hours, and hourly until 24 hours post-event 1, 2

The evidence for reversal strategies is limited (Class IIb, LOE C-EO), and the American College of Cardiology recommends not delaying treatment to obtain all laboratory results if clinical suspicion is high—initiate reversal measures while awaiting confirmation 1, 2
The American College of Cardiology recommends avoiding antiplatelet and anticoagulant therapy for at least 24 hours after the hemorrhage, and only restarting after repeat imaging confirms stability and clinical improvement 1, 2, 3