Stroke Thrombolytics: Don’t Skip Hemorrhage Risk Assessment!

Clinical Scenario

A 68-year-old man presents with right-sided weakness and slurred speech (NIHSS 12), with a negative CT, making him a clear thrombolytic candidate. As you review the risks and benefits, she seems to be on board, but asks, “What’s his chance of bleeding? Do you think it’s worth it?” You step out briefly, pull up MDCalc to better individualize the risk.

Check out the HAT and SEDAN scores on MDCalc to quickly assess post-tPA hemorrhage risk at the bedside.

Summary

HAT: Quick, simple estimate of hemorrhage risk using readily available clinical + basic CT findings.

SEDAN: More granular, imaging-informed risk estimate, incorporating additional CT features.

Tool Comparison

	HAT	SEDAN
Purpose	Predict risk of symptomatic intracranial hemorrhage (sICH) after tPA.	Predict sICH after tPA with added imaging detail.
Use When...	You want a fast, practical estimate using core clinical + basic CT data.	You want a more precise risk estimate using additional CT findings.
Scoring	Uses NIHSS, glucose, easily visible hypodensity on CT.	Uses blood glucose, NIHSS, age, early infarct signs, and hyperdense artery sign on CT.
Performance	Performs well for a quick estimate, but less robust overall.	Strong overall performance, driven by additional imaging inputs.
Workup	Uses readily available early clinical, lab, and basic CT data.	Requires more detailed imaging plus clinical and lab data.
Common Pitfalls	Subjective CT interpretation of hypodensity may lead to inconsistent scoring. Uses a single glucose cutoff, which may oversimplify risk. Variable performance across populations may limit generalizability. HAT and SEDAN use different sICH definitions (NINDS vs ECASS II), which impacts reported rates and score performance. Use these scores to guide counseling and monitoring. Not intended to withhold treatment from high-risk cases that would likely benefit from thrombolytics.	Hyperdense artery sign can be subtle and is often missed on initial CT, especially with suboptimal imaging or posterior strokes. HAT and SEDAN use different sICH definitions (NINDS vs ECASS II), which impacts reported rates and score performance. Use these scores to guide counseling and monitoring. Not intended to withhold treatment from high-risk cases that would likely benefit from thrombolytics.

Case Resolution

You review his hemorrhage risk using HAT and, given detailed CT findings are available, apply SEDAN for a more refined estimate. After a brief discussion, she agrees to proceed, and thrombolytics are administered without delay.