Management of Intracranial Hemorrhage Post-Tenecteplase
Immediately discontinue the tenecteplase infusion, obtain emergency CT imaging, and administer cryoprecipitate (10 units) or fresh frozen plasma (2-4 units) along with tranexamic acid (1 gram IV over 10 minutes) to reverse the fibrinolytic state. 1, 2
Immediate Recognition and Discontinuation
Suspect intracranial hemorrhage (ICH) if any of the following occur after tenecteplase administration:
- Change in level of consciousness 3
- Sudden elevation of blood pressure 3
- Deterioration in motor examination or increase in NIHSS score ≥4 3
- New-onset headache 3
- Nausea and vomiting 3
Stop the tenecteplase infusion immediately upon suspicion of ICH—do not wait for imaging confirmation. 3, 2
Emergency Diagnostic Workup
Obtain the following immediately:
- Emergency CT head (non-contrast) to confirm hemorrhage 3, 1
- Prothrombin time/INR 3
- Activated partial thromboplastin time (aPTT) 3
- Fibrinogen level 3
- Complete blood count with platelets 3
- Type and cross-match 3
Pharmacologic Reversal Strategy
There is no specific reversal agent for tenecteplase, but the fibrinolytic effects dissipate relatively quickly given its half-life of 65-132 minutes. 1 Management relies on replacing depleted clotting factors and inhibiting ongoing fibrinolysis:
Primary Reversal Agents:
- Cryoprecipitate: 6-10 units IV to replace fibrinogen and factor VIII 3, 1
- Fresh frozen plasma: 2-4 units IV to replace clotting factors 1
- Tranexamic acid: 1 gram IV over 10 minutes as an antifibrinolytic agent to inhibit plasminogen activation 1
Additional Measures:
- Platelet transfusion: 6-8 units if thrombocytopenia is present or patient was on antiplatelet therapy 3, 1
- Discontinue all concomitant heparin and antiplatelet agents immediately 2
Neurosurgical Consultation
Contact neurosurgery immediately for potential surgical intervention, particularly if:
- Large parenchymal hematoma with mass effect 3
- Deteriorating neurological status despite medical management 3
- Hydrocephalus from intraventricular hemorrhage 3
Blood Pressure Management
Unlike ischemic stroke, aggressive blood pressure control is critical in ICH to prevent hematoma expansion. Target systolic blood pressure <140-160 mmHg, though specific targets should be guided by neurosurgical consultation. 3
Monitoring Protocol
After ICH is identified and treated:
- Neurological assessments every 15 minutes until stabilized 3
- Complete NIHSS assessment with any change in status 3
- Repeat CT imaging at 24 hours or sooner if clinical deterioration 3
- Continuous cardiac monitoring for arrhythmias 2
Risk Context and Prevention
The incidence of symptomatic ICH after tenecteplase is approximately 0.9-1.0% in STEMI patients and 3.0% in ischemic stroke patients treated in extended windows. 3, 4 Independent predictors of ICH include:
- Advanced age (especially >75 years) 3
- Lower body weight 3
- Female gender 3
- Prior cerebrovascular disease 3
- Elevated blood pressure at presentation 3
- Higher baseline NIHSS score (>20 associated with 17% ICH risk) 3
Critical Pitfalls to Avoid
- Do not delay supportive care waiting for a "reversal agent"—none exists, and time is critical. 1
- Do not confuse tenecteplase with streptokinase—streptokinase causes antibodies and hypotension requiring different management, while tenecteplase does not. 1
- Do not use automatic blood pressure cuffs on the same arm repeatedly—rotate sites every 2 hours to prevent hematoma formation. 3
- Do not perform invasive procedures (arterial punctures, central lines, nasogastric tubes) in the first 24 hours after thrombolysis unless absolutely necessary. 3, 2
Prognosis
Outcomes depend on hemorrhage size, location, and rapidity of intervention. In the NINDS trials, symptomatic ICH occurred in 6.4% of treated patients, and early recognition with aggressive reversal improves survival and functional outcomes. 3