Symptomatic Intracerebral Hemorrhage in Acute Ischemic Stroke After Thrombolysis With Intravenous Recombinant Tissue Plasminogen Activator

IMPORTANCE: Intravenous thrombolysis remains the mainstay treatment for acute ischemic stroke. One of the most feared complications of the treatment is thrombolysis-related symptomatic intracerebral hemorrhage (sICH), which occurs in nearly 6% of patients and carries close to 50% mortality. The treatment options for sICH are based on small case series and expert opinion, and the efficacy of recommended treatments is not well known. OBJECTIVE: To provide an overview on the rationale and mechanism of action of potential treatments for sICH that may reverse the coagulopathy before hematoma expansion occurs. EVIDENCE REVIEW: Evidence-based peer-reviewed articles, including randomized trials, case series and reports, and retrospective reviews, were identified in a PubMed search on the mechanism of action of intravenous recombinant tissue plasminogen activator and the rationale of various potential treatments using the coagulation cascade as a model. The search encompassed articles published from January 1, 1990, through February 28, 2014. FINDINGS: The current treatments may not be sufficient to reverse coagulopathy early enough to prevent hematoma expansion and improve the outcome of thrombolysis-related hemorrhage. CONCLUSIONS AND RELEVANCE: Given the mechanism of action of intravenous recombinant tissue plasminogen activator, clinical studies could include agents with a fast onset of action, such as prothrombin complex concentrate, recombinant factor VIIa, and ε-aminocaproic acid, as potential therapeutic options.