(1009) Reversal of Tenecteplase With Tranexamic Acid and Cryoprecipitate

Introduction: Symptomatic intracranial hemorrhage (sICH) is a complication of fibrinolytic therapy in acute ischemic stroke. Guidelines suggest cryoprecipitate as the preferred agent for thrombolytic associated sICH, with tranexamic acid (TXA) as a second line option for patients in whom cryoprecipitate is contraindicated. These recommendations are based on studies involving alteplase and do not account for tenecteplase’s (TNK) increased resistance to plasminogen activator inhibitor-1 or its longer half-life. There is a paucity of data on the use of immediate combination therapy with TXA and cryoprecipitate to manage TNK associated sICH.

Description: A 28-year-old female was brought to the emergency room with aphasia and right-sided hemiparesis found to have a M2 occlusion. The patient received tenecteplase IV 20 mg one-hour after symptom onset and was quickly taken for a thrombectomy. Intra-procedurally, she became bradycardic requiring 1 mg of atropine and was found to have active extravasation of contrast concerning for an intracranial hemorrhage. The patient was immediately intubated for airway protection and was transported to the ICU.
A repeat CT head demonstrated extensive contrast extravasation in the subarachnoid space. Given the extent of the subarachnoid hemorrhage and recent administration of tenecteplase two hours earlier, we administered 1 gram of tranexamic acid followed by 10 units of cryoprecipitate. A fibrinogen level 1-hour after TXA and cryoprecipitate administration was 255 mg/dL, and on day 2 it was 441 mg/dL. A follow-up CT head at 24 hours showed less conspicuous blood and contrast in the left sylvian fissure compared to the prior study. The patient was extubated on hospital day 2 and was transferred out of the intensive care unit on hospital day 4. Throughout the hospital stay the patient’s neurologic function continued to improve without evidence of a new thrombus.

Discussion: This case demonstrates the safe and effective reversal of tenecteplase with concomitant use of tranexamic acid and cryoprecipitate in a high-risk sICH. Such a combination could be considered in this patient population to ensure sustained fibrinogen levels, adequate reversal of the coagulopathy, achievement of hemostasis, and minimization of neurological injury.