HAT 0 — sICH ~2 % 0

Symptomatic ICH after IV t-PA ~2 % (Lou 2008).

→ Proceed with tPA if no contraindications; adults: alteplase 0.9 mg/kg (max 90 mg): 10% as IV bolus, 90% as IV infusion over 60 minutes; BP target: < 180/105 mmHg before tPA, < 180/105 during and for 24 hours after; no antiplatelet or anticoagulant for 24 hours post-tPA; monitor neurological status and BP every 15 minutes during infusion, every 30 minutes for 6 hours, then hourly; if deterioration: CT head immediately (exclude sICH); post-tPA care in stroke unit. Children: use a children's formulary.

HAT 1 — sICH ~5 % 1

Symptomatic ICH after IV t-PA ~5 %.

→ Proceed with tPA if no contraindications; adults: alteplase 0.9 mg/kg (max 90 mg): 10% as IV bolus, 90% as IV infusion over 60 minutes; BP target: < 180/105 mmHg before tPA, < 180/105 during and for 24 hours after; no antiplatelet or anticoagulant for 24 hours post-tPA; monitor neurological status and BP every 15 minutes during infusion, every 30 minutes for 6 hours, then hourly; if deterioration: CT head immediately (exclude sICH); post-tPA care in stroke unit. Children: use a children's formulary.

HAT 2 — sICH ~10 % 2

Symptomatic ICH after IV t-PA ~10 %.

→ Discuss elevated haemorrhagic risk with patient and family as part of consent; reinforce BP control (adults: labetalol 10 mg IV or nicardipine infusion if BP > 185/110); ensure neurosurgical cover available; NIHSS and GCS monitoring every 15 minutes during tPA infusion; thrombectomy assessment if LVO present -- mechanical thrombectomy with or without tPA; stroke unit admission; if planned thrombectomy: HAT risk does not preclude tPA bridge; repeat CT at 24 hours or earlier if neurological deterioration; have fresh frozen plasma, cryoprecipitate, and platelet concentrates available in case of sICH. Children: use a children's formulary.

HAT 3 — sICH ~15 % 3

Symptomatic ICH after IV t-PA ~15 %.

→ Discuss elevated haemorrhagic risk with patient and family as part of consent; reinforce BP control (adults: labetalol 10 mg IV or nicardipine infusion if BP > 185/110); ensure neurosurgical cover available; NIHSS and GCS monitoring every 15 minutes during tPA infusion; thrombectomy assessment if LVO present -- mechanical thrombectomy with or without tPA; stroke unit admission; if planned thrombectomy: HAT risk does not preclude tPA bridge; repeat CT at 24 hours or earlier if neurological deterioration; have fresh frozen plasma, cryoprecipitate, and platelet concentrates available in case of sICH. Children: use a children's formulary.

HAT > 3 — sICH ~44 % 4–5

Symptomatic ICH after IV t-PA ~44 %.

→ Urgent multidisciplinary decision: senior stroke neurologist and/or neurosurgeon review; consider direct mechanical thrombectomy if LVO (without preceding tPA) -- thrombectomy benefit maintained and avoids tPA-related haemorrhage; if tPA only option (no thrombectomy centre): explicit informed consent documenting 44% sICH risk; CT perfusion or MR DWI-FLAIR mismatch to confirm viable penumbra; BP strictly < 180/105 mmHg; if decision to thrombolyse: neurosurgical team on standby; post-tPA intensive monitoring; if sICH occurs: stop tPA, CT immediately, neurosurgery referral, reverse coagulopathy with cryoprecipitate (fibrinogen target > 1.5 g/L) and FFP.

HAT (Haemorrhage After Thrombolysis) Score for Post-tPA Haemorrhage Risk

Score interpretation

References

Related