Table 4.
Suggestions for reversal agents that may be considered on the basis of the mechanisms of action of the agent and alteplase in patients with sICH occurring within 36 h after alteplase infusion, adapted from Yaghi et al. (34).
| Reversal agent | Suggested dose | Potential for benefit | Adverse effects |
|---|---|---|---|
| Cryoprecipitate | Consider sending a fibrinogen level immediately and empirically transfusing with 10 U cryoprecipitate, and anticipate giving more cryoprecipitate as needed to achieve a normal fibrinogen level of ≥150 mg/dL (10 U cryoprecipitate increases fibrinogen by nearly 50 mg/dL) | Potential for benefit in all sICH | Transfusion reaction and transfusion-related lung injury |
| Platelets | 2 donors (8–10 U) | Potential for benefit is unclear except in patients with thrombocytopenia (platelets <100,000/μL), who may possibly benefit | Transfusion reaction, transfusion-related lung injury, volume overload |
| FFP | 12 mL/kg | Potential for benefit is unclear except in patients on warfarin, in whom FFP may be considered | Transfusion reaction, transfusion-related lung injury, volume overload |
| PCC | 25–50 U/kg (based on INR level) | Potential for benefit is unclear except in patients on warfarin, in whom PCC may be considered and is the preferred adjunctive treatment | Thrombotic complications |
| Vitamin K | 10 mg intravenously | Potential for benefit is unclear except in patients on warfarin, in whom vitamin K may be used as an adjunctive treatment | Anaphylaxis |
| rFVIIa | 20–160 μg/kg | Potential for benefit is unclear | Thrombotic complications |
| Antifibrinolytic agents | Aminocaproic acid: 4 g IV during first hour followed by 1 g/h for 8 h Tranexamic acid: 10 mg/kg 3–4 times/d (adjustment based on kidney function may be necessary) | Potential for benefit in all patients with sICH, particularly when blood products are contraindicated or declined by patient/family or if cryoprecipitate is not available | Thrombotic complications |
FFP, fresh-frozen plasma; INR, international normalized ratio; PCC, prothrombin complex concentrate; rFVIIa, recombinant factor VIIa; and sICH, symptomatic intracranial hemorrhage.