treat hemorrhagic stroke conversion with cryoprecipitate

  • related: Neurology
  • tags: #literature #icu #neuro

IV tPa is an important intervention after acute ischemic stroke. The most important complication associated with tPa is intracerebral hemorrhage, particularly hemorrhagic conversion of the ischemic tissue in the stroke bed. The mainstay of management when a patient develops hemorrhagic conversion after tPa administration is to administer reversal medication. The half-life of the two commonly used tPa formulations in the United States is 4 to 5 min for alteplase and 17 min for tenecteplase. Despite this, the recommendations are to administer reversal medications for secondary hemorrhages up to 24 h after administration of tPa on the basis of data that (1) the fibrinogen levels do not normalize until long after the half-life of tPa and (2) tPa has been shown to adhere to clot, which can prolong its effective half-life many hours after the blood half-life. Reconstitution of factors in the coagulation cascade with focus on fibrinogen is considered the best option (cryoprecipitate).

Although checking fibrinogen levels makes sense, guidelines suggest that fibrinogen levels may not predict future bleeding risk, and definitive treatment should not be delayed while awaiting results. Fibrinogen levels are recommended to guide adequacy of initial therapy, and low levels should prompt additional cryoprecipitate doses. Activated factor VIIa has been tried in case series, but expert opinion suggests that cryoprecipitate, rich in fibrinogen, is a more appropriate treatment.1234

Footnotes

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  2. Mac Grory B, Saldanha IJ, Mistry EA, et al. Thrombolytic therapy for wake-up stroke: a systematic review and meta-analysis. Eur J Neurol. 2021;28(6):2006-2016. PubMed ↩

  3. Matosevic B, Knoflach M, Werner P, et al. Fibrinogen degradation coagulopathy and bleeding complications after stroke thrombolysis. Neurology. 2013;80(13):1216-1224. PubMed ↩

  4. Yaghi S, Willey JZ, Cucchiara B, et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Quality of Care and Outcomes Research. Treatment and outcome of hemorrhagic transformation after intravenous alteplase in acute ischemic stroke: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2017;48(12):e343-e361. PubMed ↩