Stopping What You Started: Hemostatic Therapy for Thrombolytic-Associated Hemorrhagic Conversion

While anticoagulation reversal for anticoagulant-associated bleeding gets a lot of press (see recent publication of ANNEXA-I and the seemingly endless discourse that followed) 1 , the approach to handling bleeding secondary to thrombolysis is arguably more controversial and certainly less clear cut. Entire guidelines and bodies of evidence have explored ideal reversal strategies for warfarin, factor Xa inhibitors, other anticoagulants, and antiplatelets, but discussion surrounding what to do when a patient experiences major bleeding after thrombolysis is generally relegated to a small section of review articles and guidelines with a simple explanation for the brevity – there just isn’t a lot of evidence guiding what to do. A patient who developed significantly worsening level of arousal and worse left-sided facial droop ~2 hours after receiving tenecteplase. She received cryoprecipitate and tranexamic acid and eventually required a decompressive hemicraniectomy. She required inpatient