This article summarizes 5 common complications after thrombolysis and their management

Intravenous thrombolysis for acute ischemic stroke is the most effective treatment at present, but the complications caused by intravenous thrombolysis cannot be ignored.

Intravenous thrombolysis for acute ischemic stroke is the most effective treatment at present, but the complications caused by intravenous thrombolysis cannot be ignored.

intracerebral hemorrhagic transformation

According to the "China Consensus on Diagnosis and Treatment of Hemorrhagic Transformation after Acute Cerebral Infarction 2019" [1], hemorrhagic transformation refers to hemorrhage caused by the restoration of blood perfusion in the ischemic area after acute cerebral infarction, including naturally occurring hemorrhage (spontaneous hemorrhagic transformation) and Bleeding (secondary/therapeutic hemorrhagic transformation) after interventions including thrombolysis, thrombectomy, and anticoagulation

According to the "China Consensus on Diagnosis and Treatment of Hemorrhagic Transformation after Acute Cerebral Infarction 2019" [1], hemorrhagic transformation refers to hemorrhage caused by the restoration of blood perfusion in the ischemic area after acute cerebral infarction, including naturally occurring hemorrhage (spontaneous hemorrhagic transformation) and Bleeding (secondary/therapeutic hemorrhagic transformation) after interventions including thrombolysis, thrombectomy, and anticoagulation

According to the results of the NINDS study, 96% of hemorrhagic transformation occurred within 36 hours after intravenous thrombolysis.

The occurrence of cerebral hemorrhagic transformation spans a wide range, which is usually directly related to the dose of thrombolytic drugs, the time window of thrombolysis, and the severity of stroke

The occurrence of cerebral hemorrhagic transformation spans a wide range, which is usually directly related to the dose of thrombolytic drugs, the time window of thrombolysis, and the severity of stroke

The general principles of management of hemorrhagic transformation are similar to those of spontaneous intracerebral hemorrhage, including circulatory and respiratory support as necessary, blood pressure management , monitoring of neurological deterioration, prevention of hematoma expansion, treatment of intracranial hypertension, and management of other complications of hemorrhage including: Epilepsy and other symptomatic treatment

At the same time, antithrombotic and rt-PA and other bleeding-causing drugs should be discontinued for symptomatic hemorrhagic transformation: if necessary for symptomatic hemorrhagic transformation after thrombolysis, adjunctive use of drugs for reversing coagulation disorders, including cryoprecipitate, fibrinogen, and anti-fibrinogen, should be considered.

Vascular reocclusion after thrombolysis

Data show that approximately 11.

Data show that approximately 11.

For the management of vascular reocclusion, there is no unified treatment plan in the major guidelines

Brain edema after thrombolysis Brain edema after thrombolysis

Brain edema after thrombolysis generally occurs within 24-48 hours after thrombolysis, and can manifest as symptoms of high intracranial pressure (headache, vomiting, papilledema), deterioration of neurological function, changes in state of consciousness, and brain herniation may occur in severe edema

Brain edema after thrombolysis generally occurs within 24-48 hours after thrombolysis, and can manifest as symptoms of high intracranial pressure (headache, vomiting, papilledema), deterioration of neurological function, changes in state of consciousness, and brain herniation may occur in severe edema

Studies have shown that patients with malignant middle cerebral artery infarction are prone to severe cerebral edema, suggesting that cerebral edema is related to infarct size and location

The occurrence and development of cerebral edema after thrombolysis may be related to the higher NIHSS score, high-density cerebral artery sign, the presence of early infarction signs, and treatment delay in patients before thrombolysis

Management of cerebral edema after thrombolysis includes raising the head of the bed 30°, using dehydrating drugs, diuretics, and hormones, surgical decompressive craniectomy, and improving the patient's general status
.

Angioedema

angioedema angioedema

Orolingual angioedema, a potentially life-threatening complication, may occur in patients with acute ischemic stroke following intravenous rt-PA therapy, and it is estimated that in all cases the occurrence of oral and lingual edema The rate is 1.
7% to 7.
9% [3]
.

Orolingual angioedema, a potentially life-threatening complication, may occur in patients with acute ischemic stroke following intravenous rt-PA therapy, and it is estimated that in all cases the occurrence of oral and lingual edema The rate is 1.
7% to 7.
9% [3]
.

Orolingual angioedema is considered an anaphylactoid reaction rather than a true anaphylactic reaction
.
This complication is thought to result from rt-PA-mediated elevation of bradykinin and histamine levels, and is influenced by several other factors, such as autonomic dysfunction at the site of stroke involving the insular cortex, and concomitant use of Certain medications, such as angiotensin-converting enzyme inhibitors (ACEIs)
.
Treatment includes antihistamines, steroids, complement inhibitors, and airway protection
.

Orolingual angioedema is considered an anaphylactoid reaction rather than a true anaphylactic reaction
.
This complication is thought to result from rt-PA-mediated elevation of bradykinin and histamine levels, and is influenced by several other factors, such as autonomic dysfunction at the site of stroke involving the insular cortex, and concomitant use of Certain medications, such as angiotensin-converting enzyme inhibitors (ACEIs)
.
Treatment includes antihistamines, steroids, complement inhibitors, and airway protection
.

First of all, before thrombolysis, you should routinely ask whether there is an ACEI or ARB drug, and if you take it, stop it as soon as possible
.
Second, for patients with angioedema, the infusion of rt-PA should be stopped immediately, and the patient should be given diphenhydramine 50 mg and famotidine 20 mg intravenously immediately
.
If angioedema continued to progress, methylprednisolone 125 mg or subcutaneous epinephrine 0.
3 mg was further considered, and urgent airway protection intervention was requested from the anesthesiologist
.

First of all, before thrombolysis, you should routinely ask whether there is an ACEI or ARB drug, and if you take it, stop it as soon as possible
.
Second, for patients with angioedema, the infusion of rt-PA should be stopped immediately, and the patient should be given diphenhydramine 50 mg and famotidine 20 mg intravenously immediately
.
If angioedema continued to progress, methylprednisolone 125 mg or subcutaneous epinephrine 0.
3 mg was further considered, and urgent airway protection intervention was requested from the anesthesiologist
.

allergic reaction

allergic reaction allergic reaction

Allergic reactions are uncommon adverse reactions of thrombolytic therapy, with a probability of 0.
1%-1%, mainly manifested as rash, urticaria, bronchospasm, angiogenic edema, hypotension, shock and other symptoms related to allergic reactions [ 4]
.

Allergic reactions are uncommon adverse reactions of thrombolytic therapy, with a probability of 0.
1%-1%, mainly manifested as rash, urticaria, bronchospasm, angiogenic edema, hypotension, shock and other symptoms related to allergic reactions [ 4]
.

If rash and angioedema are found during thrombolysis, immediate discontinuation of the drug may be considered
.
Mild symptoms can be closely observed, no medication or early administration of antihistamines and steroids if necessary
.
Symptoms progress rapidly, and epinephrine nebulization may be considered
.
When airway obstruction occurs, tracheotomy should be performed in time to keep the airway open to avoid respiratory failure, and mechanical ventilation should be performed if necessary
.

If rash and angioedema are found during thrombolysis, immediate discontinuation of the drug may be considered
.
Mild symptoms can be closely observed, no medication or early administration of antihistamines and steroids if necessary
.
Symptoms progress rapidly, and epinephrine nebulization may be considered
.
When airway obstruction occurs, tracheotomy should be performed in time to keep the airway open to avoid respiratory failure, and mechanical ventilation should be performed if necessary
.

In conclusion, complications after thrombolysis lead to early neurological deterioration, and early recanalization may reduce the incidence of complications
.
The occurrence of complications after thrombolysis is related to a variety of factors.
The specific treatment measures need to integrate the systemic state, and there is no big data to support the targeted treatment plan
.
How to reduce complications after thrombolysis still needs more research
.

In conclusion, complications after thrombolysis lead to early neurological deterioration, and early recanalization may reduce the incidence of complications
.
The occurrence of complications after thrombolysis is related to a variety of factors.
The specific treatment measures need to integrate the systemic state, and there is no big data to support the targeted treatment plan
.
How to reduce complications after thrombolysis still needs more research
.

[1] Chinese Medical Association Neurology Branch, Chinese Medical Association Neurology Branch Cerebrovascular Disease Group.
Chinese Consensus on Diagnosis and Treatment of Hemorrhagic Transformation after Acute Cerebral Infarction 2019 [J].
Chinese Journal of Neurology, 2019,52(4):252- 265.

[1] Chinese Medical Association Neurology Branch, Chinese Medical Association Neurology Branch Cerebrovascular Disease Group.
Chinese Consensus on Diagnosis and Treatment of Hemorrhagic Transformation after Acute Cerebral Infarction 2019 [J].
Chinese Journal of Neurology, 2019,52(4):252- 265.

[2] Chinese Stroke Society, Neurointerventional Branch of Chinese Stroke Society, Interventional Group of Stroke Prevention and Control Professional Committee of Chinese Preventive Medicine Association.
Chinese Guidelines for Endovascular Treatment of Acute Ischemic Stroke 2018 [J].
Chinese Journal of Stroke, 2018,13 (7): 706-729.
DOI: 10.
3969/j.
issn.
1673-5765.
2018.
07.
014.

[2] Chinese Stroke Society, Neurointerventional Branch of Chinese Stroke Society, Interventional Group of Stroke Prevention and Control Professional Committee of Chinese Preventive Medicine Association.
Chinese Guidelines for Endovascular Treatment of Acute Ischemic Stroke 2018 [J].
Chinese Journal of Stroke, 2018,13 (7): 706-729.
DOI: 10.
3969/j.
issn.
1673-5765.
2018.
07.
014.

[3] FDLRL Rosa et al.
Thrombolysis of a stroke patient with history of rtPA-associated angioedema[J].
Neurol Clin Pract.
2017 Dec;7(6):541-543.

[3] FDLRL Rosa et al.
Thrombolysis of a stroke patient with history of rtPA-associated angioedema[J].
Neurol Clin Pract.
2017 Dec;7(6):541-543.

[4] Krmpotic KR et al.
Anaphylactoid reaction to recombinant tissue plasminogen activator [J].
Eur J Emerg Med, 2007, 14(1): 60-1.

[4] Krmpotic KR et al.
Anaphylactoid reaction to recombinant tissue plasminogen activator [J].
Eur J Emerg Med, 2007, 14(1): 60-1.

 

leave a message here