To identify factors related to the timing of symptomatic intracerebral hemorrhage (sICH) after thrombolysis.

Intensive monitoring for 24 hours following intravenous alteplase (tPA) for acute ischemic stroke is recommended for blood pressure control and early detection of neurologic changes that may indicate sICH. Considering increasing pressure on critical care capacity and low rates of sICH, characterizing the highest risk period and patients could optimize critical care through-put.

Data retrospectively collected from medical records included patients treated with tPA complicated by sICH from 3/2012-12/2019. Median tests were used to determine any difference in time from tPA bolus to sICH detection, by demographics, admission NIHSS, antithrombotic therapy and blood pressure treatment. Correlations values were computed to investigate relationships between time sICH detected and: time last known well (LKW), time treated, and systolic blood pressure (SBP).

Eighty-five patients were included. Median time from treatment to sICH was 6.4hr [IQR2.4, 16.3]. Median tests showed no significant differences in time to sICH between patients that did and did not have the following: blood pressure treated (9.6 versus 5.6; p = 0.189), history of antiplatelets (6.4 versus 6.7; p = 0.906), history of anticoagulants (3.5 versus 7.9; p = 0.416), highest SBP above 180 mmHg before treatment (3.2 versus 6.0; p = 0.451). Time to sICH correlated weakly with NIHSS (ρ = 0.18), but did not correlate with age (ρ = -0.07), LKW to treatment time (ρ = -0.05), highest SBP before (ρ = -0.03), SBP closest to (ρ = -0.11), nor highest SBP after treatment (ρ = -0.04).

In this largest known cohort of patients with sICH after tPA, only NIHSS weakly correlates to time to sICH detection. Continued pragmatic evaluations comparing those who hemorrhage with those that don’t to predict risk of sICH after thrombolysis are needed to individualize critical care utilization.