Table 9.

Guidelines for management within the first 24 h after initiation of intravenous thrombolysis

Neurologic assessment Neurological findings are investigated frequently (every at least 30 min from initiation of administration to 8 h, every 1 h from 8 to 24 h) within 24 h after initiation of administration to monitor for acute worsening. If severe headache, nausea, vomiting, acute increase in blood pressure, or worsening of neurologic deficits develops, because of suspected concurrent intracerebral hemorrhage and hemorrhagic infarct, an emergent CT scan should be performed. If patients are receiving alteplase, treatment should be discontinued immediately. Blood pressure (BP) measurement The BP should be measured frequently (suggested frequency: every 15 min from initiation of administration to 2 h, every 30 min from 2 to 8 h, every 1 h from 8 to 24 h) within 24 h after initiation of administration, and systolic BP or diastolic BP should not exceed 180 or 105 mmHg, respectively. If a systolic BP level of >180 mmHg or a diastolic BP level of >105 mmHg is recorded, BP should be checked more frequently, and antihypertensive therapy be initiated to maintain BP under these thresholds. Antihypertensive agents should be chosen according to the Japanese Society of Hypertensions Guidelines for the Management of Hypertension 2014 (Table 10). Mechanical thrombectomy In patients with the large vessel occlusion in the anterior circulation, the eligibility for mechanical thrombectomy should be determined immediately, and if patients are considered eligible for thrombectomy, the therapy should be initiated immediately. Control of blood pressure is in accordance with management after initiation of alteplase. Other precautions Patients should be managed at SCUs (or intensive care units) or their equivalent wards in medical institutions that have CT (MRI) scans available 24 h a day. Insertion of nasogastric tubes, bladder catheters, and arterial pressure measuring catheters should be avoided immediately after initiation of treatment and delayed whenever possible. Restriction of antithrombotic therapies within 24 hours of treatment. The use of heparin (≤10,000 units) during angiography or for the prevention of deep venous thrombosis is allowed, in which case the risk of intracranial hemorrhage should be considered. If bleeding tendency such as hematuria, gingival bleeding, subcutaneous hemorrhage, and bleeding from catheter puncture sites, or swelling in tongue, lip, face, pharynx, and larynx (angioedema) develops, appropriate measures should be implemented. When clinically significant adverse drug reactions are suspected, such as serious hemorrhage (gastrointestinal hemorrhage, pulmonary hemorrhage, retroperitoneal hemorrhage, etc.) or airway narrowing associated with laryngeal edema, if patients are on alteplase, treatment should be discontinued. Procedures for sICH Primary care Blood pressure control—Blood pressure should be reduced to normal levels (approximately 140 mmHg for systolic blood pressure) to prevent hematoma growth. Respiratory management—If respiratory/ventilatory disturbance is present, the airway should be secured by tracheal intubation and respiration be assisted as appropriate. Management of cerebral edema/intracranial pressure—Anti-brain edema agents should be used. Prevention of peptic ulcer—Antiulcer agents should be used. If progressive deterioration of neurologic deficits and the following CT findings are observed, surgical treatment should be considered Local mass effect. Medium-sized putaminal or subcortical hematoma. Cerebellar hemorrhage (≥3 cm in maximum diameter). Brain stem compression, hydrocephalus.