Emergency Department Management of Postthrombolysis Intracranial Hemorrhage (Stroke CME and Pharmacology CME)

Publication Date: August 2026 (Volume 28, Number 8)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 08/01/2029.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Stroke CME credits and 1 Pharmacology CME credit, subject to your state and institutional approval.

Author

Syeda Maria Muzammil, MD

Assistant Professor, Department of Neurology, Division of Neurocritical Care, Detroit Medical Center/Wayne State University School of Medicine, Detroit, MI

Guest Editor-in-Chief

Rhonda Cadena, MD, FNCS, FCCM

Clinical Associate Professor, Wake Forest School of Medicine; Neurocritical Care, Atrium Health, Carolinas Medical Center, Charlotte, NC

Abstract

Intracranial hemorrhage following intravenous thrombolytic therapy most commonly occurs within 12 hours of administration. Because many patients remain in the emergency department during this period, a structured, time-sensitive approach to recognition and management is critical. This review summarizes current recommendations for the diagnostic workup, use of reversal agents, and escalation of care for postthrombolysis intracranial hemorrhage, with particular attention to guidelines addressing stroke and neurocritical care management. Contraindications to intravenous thrombolysis and risk factors for postthrombolysis intracranial hemorrhage are also discussed.

Case Presentations

CASE 1

A 75-year-old woman presents with aphasia and mild right hemiparesis…

Her initial NIHSS score is 4. She arrives at the ED within 3 hours of her last known well and receives IV tenecteplase.
Forty-five minutes after tenecteplase administration, you are called to reassess the patient. You quickly ensure adequate airway protection and note she now has a left gaze preference, right facial droop, worsening aphasia, worsened right hemiparesis, and right hemineglect, with an NIHSS score of 10.
Her blood pressure has increased to 190/100 mm Hg, despite administration of IV nicardipine 12.5 mg/hr.
Noncontrast CT of the head shows interval development of parenchymal and subarachnoid hemorrhages in the left parietal region.
You alert neurology and wonder if this patient requires reversal of the tenecteplase and how you should manage her blood pressure...

CASE 2

A 62-year-old woman presents with isolated aphasia…

She is brought in by EMS, who report that the patient’s last known well was 45 minutes prior to arrival.
Following evaluation and neuroimaging, she is diagnosed with acute ischemic stroke and receives IV alteplase.
She later develops a pontine hemorrhage.
You wonder if there were any factors that may have increased her hemorrhage risk…

CASE 3

A 65-year-old man presents with forced right gaze, dense left hemiplegia, and left hemisensory neglect…

Noncontrast CT of the head is negative for hemorrhage. CT angiography of the head shows an occlusive thrombus in the right M1 segment of the middle cerebral artery.
The patient has no contraindications to thrombolysis and receives IV tenecteplase within 2 hours of last known well, followed by mechanical thrombectomy for large vessel occlusion.
Postprocedure CT of the head shows a new right frontal hemorrhage. On examination, you find no neurological deterioration.
You wonder if you are missing subtle worsening, and whether you should initiate reversal...

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.