Bleeding Risk (Continued) COR LOE New, Revised, or Unchanged Table 6. Management of Symptomatic Intracranial Bleeding Occurring Within 24 Hours After Administration of IV Alteplase for Treatment of AIS COR IIb LOE C-EO Stop alteplase infusion CBC, PT (INR), aPTT, fibrinogen level, and type and cross-match Emergent nonenhanced head CT Cryoprecipitate (includes factor VIII): 10 U infused over 10 30 min (onset in 1 h, peaks in 12 h); administer additional dose for fibrinogen level of <150 mg/dL Tranexamic acid 1000 mg IV infused over 10 min OR -aminocaproic acid 4 5 g over 1 h, followed by 1 g IV until bleeding is controlled (peak onset in 3 h) (Potential for benefit in all patients, but particularly when blood products are contraindicated or declined by patient/family or if cryoprecipitate is not available in a timely manner.) Hematology and neurosurgery consultations Supportive therapy, including BP management, ICP, CPP, MAP, temperature, and glucose control AIS indicates acute ischemic stroke; aPTT, activated partial thromboplastin time; BP, blood pressure; CBC, complete blood count; COR, class of recommendation; CPP, cerebral perfusion pressure; CT, computed tomography; ICP, intracranial pressure; INR, international normalized ratio; IV, intravenous; LOE, Level of Evidence; MAP, mean arterial pressure; and PT, prothrombin time. Sources: Sloan et al,138 Mahaffey et al,139 Goldstein et al,140 French et al,141 Yaghi et al,142 144 Stone et al,145 and Frontera et al.146 Table 7. Management of Orolingual Angioedema Associated With IV Alteplase Administration for AIS COR IIb LOE C-EO Maintain airway Endotracheal intubation may not be necessary if edema is limited to anterior tongue and lips. Edema involving larynx, palate, floor of mouth, or oropharynx with rapid progression (within 30 min) poses higher risk of requiring intubation. Awake fiberoptic intubation is optimal. Nasal-tracheal intubation may be required but poses risk of epistaxis after IV alteplase. 