An 82 yo F with a history of HTN, DM, CAD, GERD presents to the ED with expressive aphasia that started 1hour prior to arrival. On exam, she has difficulty answering questions but follows commands. CT head is negative, neurology in consulted and tPA is given. An hour later, you are called back into the room for worsening neurologic exam. The patient is awake but not speaking and is unable to follow commands. A stat repeat head CT is ordered and shown below. What's the diagnosis? (scroll down for answer) 

Answer: Intraparenchymal hemorrhage s/p TPA

• Any change in exam after tPA requires STAT repeat imaging
• Risk of intracerebral hemorrhage after tPA is ~ 6%
• Risk factors include: older age, increased stroke severity, hyperglycemia, uncontrolled HTN, antiplatelet use, ischemic changes on CT 
• Results in higher morbidity and mortality
• Hemorrhage starts in the infarcted brain tissue
• Options to reverse tPA effects
• Antifibrinolytics: Aminocaproic acid, TXA
• Coagulation factors: FFP, Prothrombin complex concentrates (PCC), Cryoprecipitate
• Platelet transfusion 
• Other tPA complications include systemic hemorrhage and angioedema

References: 

Miller DJ, Simpson JR, Silver B. Safety of thrombolysis in acute ischemic stroke: a review of complications, risk factors, and newer technologies. Neurohospitalist. 2011;1(3):138–147.

Lansberg MG, Alberts GW, Wijman CAC. Symptomatic intracerebral hemorrhage following thrombolytic therapy for acute ischemic stroke: a review of the risk factors. Cerebrovasc Dis. 2007;24:1-10. 

Yaghi S, Eisenberger A, Willey JZ. Symptomatic intracerebral hemorrhage in acute ischemic stroke after thrombolysis with intravenous recombinant tissue plasminogen activator: a review of natural history and treatment. JAMA Neurol. 2014;71(9):1181–1185.