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Post-Thrombolysis Haemorrhage – Management — SCE Neurology MCQ

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ModerateCerebrovascular DiseasePost-Thrombolysis Haemorrhage – ManagementSCE Neurology

A 60-year-old man receives IV alteplase for acute ischaemic stroke. Two hours later, he develops sudden severe headache, vomiting, and rapid neurological deterioration. His GCS falls from 14 to 7. What is the most likely complication, and what is the immediate management?

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Correct answer: C — Symptomatic intracranial haemorrhage — stop the alteplase infusion (if still running), urgent CT head, check coagulation, give cryoprecipitate and tranexamic acid

Symptomatic intracranial haemorrhage (sICH) occurs in approximately 6% of patients receiving IV alteplase and is the most feared complication. Clinical deterioration within hours of thrombolysis should be assumed to be sICH until proven otherwise. Management: (1) stop the alteplase infusion immediately if still running, (2) urgent CT head to confirm haemorrhage, (3) check coagulation (fibrinogen, PT, aPTT, platelets), (4) give cryoprecipitate (to replace fibrinogen) and tranexamic acid (antifibrinolytic), (5) reverse any coagulopathy, (6) neurosurgical consultation. A: Seizure is possible but haemorrhage must be excluded first. C: Never re-dose alteplase. D: Anaphylaxis has different features. E: Migraine is not the likely diagnosis.

Reference: RCP National Clinical Guideline for Stroke (2023); NICE NG128