Clinical Characteristics and In-Hospital Course of Symptomatic Intracranial Hemorrhage After Intravenous Alteplase in Older Adults with Acute Ischemic Stroke: A Retrospective Cohort Study

Background/Objectives: This study describes symptomatic intracranial hemorrhage (sICH) after intravenous alteplase in older adults with acute ischemic stroke. Methods: This retrospective single-center cohort included 95 unique patients aged ≥65 years treated in Galati, Romania, in 2020–2024. The binary hemorrhage variable was verified against clinical and computed tomography (CT) records. Study-defined sICH required new or increased CT hemorrhage with attributed deterioration, comprising a ≥4-point National Institutes of Health Stroke Scale (NIHSS) increase or other clinically relevant worsening. Comparisons and Firth models were exploratory, with admission NIHSS adjustment. Results: All 14 recorded hemorrhages met this definition (14.7%; 95% CI 9.0–23.2%): 10 met the NIHSS threshold and four had relevant worsening below it. Ten were detected before 24 h and four at the 24–48 h range; morphology included hemorrhagic infarction and parenchymal hematoma. All adjusted intervals included the null. Median hospitalization was five days longer with sICH. The mortality difference was 2.6 percentage points (conservative exact 95% CI range from −31.6 to 45.9). Conclusions: Adjusted association estimates are inconclusive and do not justify altering guideline-based eligibility. Prospective multicenter studies require standardized definitions, stroke-severity measures, reperfusion data, and functional outcomes.