1. Emergency management of complications of thrombolysis C. Roffe The recommendations in this presentation are for guidance only. Guidance based on ASA recommendations 2007, EUSI recommendations 3003, Lancet Feb 2007 and IST-3 training folder (as indicated).

2. Suspicion of Intracranial Haemorrhage (headache, neurological deterioration, reduced consciousness, seizure, N&V) Stop alteplase infusion Immediate non contrast CT head Immediate PT, APTT, fibrinogen FBC Group and save Prepare 6 units cryoprecipitate Prepare 6 units platelets Haemorrhage on CT? Check lab results Give cryoprecipitate and platelets Notify Neurosurgeons Resume alteplase infusion YES NO Khaja, Lancet 2007; 396:319-330.

3. Extracranial bleeding (drop in blood pressure, shock, evidence of blood loss e.g. melaena, haematuria) Stop alteplase infusion Immediate PT, APTT, fibrinogen, FBC, group and save IST-3 thrombolysis training manual. Use mechanical compression, if possible, to control bleeding form puncture sites Support circulation with fluids and blood transfusion, as appropriate For severe life threatening bleeding tranexamic acid 1 g i.v. over 15 min, repeated at 8 h if needed Consider transfusion of FFP and/or cryoprecipitate depending on the results of the coagulation screen

4. Orololingual Angiooedema (swollen lips or tongue, dyspnoea) Stop alteplase infusion Antihistamines (clorpheniramine 10 mg i.v.) Hydrocortisone 200 mg i.v. Khaja, Lancet 2007; 396:319-330. Observe vital for signs of progression, dyspnoea, anaphylactic shock If sx are mild and non-progressive, alteplase can be restarted under close observation

5. Anaphylaxis (rash, urticaria, dyspnoea, bronchospasm, angiooedema, hypotension, shock) Stop alteplase infusion Adrenaline 0.5 -1 ml 1:1000 im or sc (not iv) Clorpheniramine 10 mg i.v. Hydrocortisone 200 mg i.v. Salbutamol nebulizer 5 mg IST-3 thrombolysis training manual. Urgent medical assessment: Airway, Breathing, Circulation If shocked i.v. saline and consider repeat doses of adrenaline

6. Hypertension within 24 hours of thrombolysis (BP > 185/110) Labetalol 10-20 mg over 1-2 min (onset of action 5-10 min, duration 3-5h) repeat PRN q10-20 min Followed, if necessary, by an infusion at 0.5-2 mg/min, max dose 200 mg/24 h (1, 2) GTN infusion start with 5 mcg/min titrate as necessary Or GTN patch 5 mg (1, 2) Aim to reduce BP slowly (not more than 10-20 mm Hg in the first hour, not more than 50 mm Hg in 24 h Ensure appropriate continuation of treatment to avoid resurgence hypertension Captopril 6.25 mg po/sc (sc effective in 15-30 min, duration 4-6h) (1, 2) 1. AHA/ASA Stroke 2007;38:1655-1711. 2. ESC recommendations. Cerebrovasc Dis 2003; 16:311-337. Nitroprusside 0.25-10 mcg/kg/min (onset of action: 1-5 min) (1, 2) or If nothing helps

7. Reperfusion cerebral oedema (agitation, clouding of consciousness, seizures, neurological deterioration within 24- 48 h of alteplase infusion and no haemorrhage on CT head scan) Elevate the head to 30 degrees Correct hyperthermia, hypoxia, hyperglycaemia, hypotension AHA/ASA Stroke 2007;38:1655-1711. *as used by C. Roffe in Stoke, not in AHA/ASA guidance (See also Bardutsky Stroke 2007;38;3084-94 for a review of antioedema strategies in cerebral oedema ) If symptoms improve with mannitol reduce dose/frequency gradually Mannitol 0.25-0.5 g/kg over 20 min i.v. (e.g. 100-200ml 20%mannitol for 80 kg), repeat q 4-8 h, if necessary Dexamethasone 4 mg iv qds* Frusemide 20-40 mg iv* Avoid antihypertensives, especially vasodilators Consider decompressive hemicraniectomy (once clotting correct/corrected)