Critical Care Medicine-Neurologic Disorders>>>>>Cerebrovascular Diseases
Question 8#

A 69-year-old female with hypertension presents to the emergency department from home following acute onset of slurred speech and left facial droop. She was with her family watching television when her daughter noted the symptoms. Emergency medical services (EMS) was called and noted left facial droop, left arm weakness, and dysarthria. Her initial vitals were unremarkable other than a BP of 212/92. She was treated with IV labetolol with BP improvement and was treated with IV tPA. Thirty minutes into the infusion she complained of a headache and became less responsive. Her BP was 190/86, and the tPA was stopped. A repeat head CT was completed and is shown in the figure that follows:

Axial noncontrast head CT. There is a large right MCAacute ischemic stroke with edema and effacement of the sulci. There is hemorrhage present within the area of ischemia centered in the right basal ganglia and insula.

Other than BP management, what is the next best step in management of her current neurologic issue?

A. Administration of 10 mg IV vitamin K followed by 5 mg IV daily for 3 days
B. Administration of at least 2500 units of prothombin complex concentrate
C. Administration of aminocaproic acid (Amicar) 10 g IV in 250 mL NS IV over 1 hour or TXA with load of 1 g over 10 minutes and 1 g over the following 8 hours
D. Administration of cryoprecipitate
E. Administration of fresh frozen plasma

Correct Answer is D


Correct Answer: D

For every 100 patients treated with tPA, 1 patient will experience a severely disabled or fatal outcome as a result of tPA-related hemorrhage. The treatment of symptomatic hemorrhage following tPA administration has not been studied in a randomized fashion. In patients with hypofibrinoemia (level <150 mg/dL) post tPA, cryoprecipitate is recommended to increase this level as those with low fibrinogen had hematoma expansion and worse outcomes. Although fresh frozen plasma contains the same clotting factors as cryoprecipitate, they are not as concentrated and would require a larger volume and would not correct the low fibrinogen level as quickly. TXA and aminocaproic acid can be used for uncontrolled and life-threatening hemorrhage following tPA administration, but these should not be considered first-line therapy, given the complications of prothrombic state that can occur. The dose noted for TXA listed above was studied in trauma patients and demonstrated decreased risk of death. Lastly, use of prothrombin complex concentrate and vitamin K can be used for vitamin K antagonist hemorrhage but play little role in treatment of tPA hemorrhage.


  1. The NINDS t-PA Stroke study Group. Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. Stroke. 1997;28:2109-2118.
  2. Morgenstern LB, Hemphill JC III, Anderson C, et al. Guidelines for the management of spontaneous intracerebal hemorrhage: a guideline for healthcare professionals for the American Heart Association/American Stroke Association. Stroke. 2010;41:2108-2129.