What products are needed for a craniotomy in an adult patient who received alteplase (tissue plasminogen activator) for acute ischemic stroke 11 hours prior?

Emergency Craniotomy After Alteplase: Required Blood Products and Reversal Strategy

You need cryoprecipitate (10 units) and tranexamic acid (1000 mg IV) or ε-aminocaproic acid (4-5 g loading dose) to reverse alteplase's fibrinolytic effects before emergency craniotomy. 1

Immediate Reversal Protocol

The American Heart Association guidelines for managing bleeding complications after alteplase provide the specific reversal strategy applicable to your emergency surgical situation 1:

Primary Reversal Agents

• Cryoprecipitate: Administer 10 units IV over 10-30 minutes 1

  • Contains factor VIII and fibrinogen
  • Onset of action in 1 hour, peaks at 12 hours 1
  • Give additional doses if fibrinogen level remains <200 mg/dL 1

• Antifibrinolytic therapy (choose one) 1:

  • Tranexamic acid: 1000 mg IV infused over 10 minutes, OR
  • ε-aminocaproic acid: 4-5 g IV over 1 hour, followed by 1 g IV continuous infusion until bleeding controlled (peak onset in 3 hours) 1

Essential Laboratory Assessment

Before proceeding to surgery, obtain 1:

• Complete blood count (CBC)
• Prothrombin time (PT/INR)
• Activated partial thromboplastin time (aPTT)
• Fibrinogen level (critical for guiding additional cryoprecipitate dosing)
• Type and cross-match for packed red blood cells

Timing Considerations

Critical pitfall: While alteplase has a short elimination half-life of 4-24 minutes, its systemic fibrinolytic effects persist much longer than the drug's plasma half-life 2. At 11 hours post-alteplase, significant coagulopathy may still be present, particularly affecting fibrinogen levels and clot stability 2.

Neurosurgical Consultation

• Immediate neurosurgery consultation is mandated by AHA guidelines for any bleeding complication after alteplase 1
• Hematology consultation should also be obtained 1

Supportive Measures During Surgery

Maintain optimal conditions for hemostasis 1:

• Blood pressure management (avoid hypertension)
• Intracranial pressure monitoring and control
• Cerebral perfusion pressure optimization
• Temperature control (avoid hyperthermia)
• Glucose control (avoid hyperglycemia)

Blood Product Availability

Ensure immediate availability in the operating room:

• Multiple units of packed red blood cells (cross-matched)
• Additional cryoprecipitate units on standby
• Fresh frozen plasma (FFP) if INR becomes elevated
• Platelets if count drops below 100,000/mm³ 1

Common Pitfall to Avoid

Do not proceed to craniotomy without administering reversal agents first. The 2018 AHA/ASA guidelines specifically outline this reversal protocol for symptomatic intracranial bleeding within 24 hours of alteplase, which applies to your surgical bleeding risk scenario 1. The fibrinolytic state induced by alteplase creates unacceptable surgical bleeding risk without reversal, even 11 hours after administration 2.