Pericardial Tamponade After Systemic Alteplase in Stroke andEmergent Reversal With Tranexamic Acid

• Type of Material: Article
• Authors: Cynthia Romero, Emory University; Samuel Shartar, Emory University; Michael Carr, Emory University
• Language: English
• Date: 2020-01-04
• Publisher: eScholarship Publishing, University of California
• Publication Version: Final Published Version
• Copyright Statement: © 2020 Romero et al.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.5811/cpcem.2019.10.44369
• Title of Journal or Parent Work: Clinical Practice and Cases in Emergency Medicine
• ISSN: 2474-252X
• Volume: 0
• Issue: 0
• Grant/Funding Information: This article published with support from Emory Libraries' Open Access Publishing Fund.
• Keywords: hypotension; plasmin; cardiac tamponade; pulse; tissue plasminogen activator; acute ischemic stroke; etiology; alteplase; ultrasound; cryoprecipitate; tranexamic acid; major bleeding; antagonist; clot; fibrinolysis; pericardiocentesis

Abstract

Alteplase, or tissue plasminogen activator (tPA), lyses clots by enhancing activation of plasminogen to plasmin. Conversely, tranexamic acid (TXA) functions by inhibiting the conversion of plasminogen to plasmin, which inhibits fibrinolysis. TXA has proven safe and effective in major bleeding with various etiologies. A 76-year-old male developed acute ischemic stroke symptoms. Systemic alteplase was administered and he showed clinical improvement. Shortly thereafter, the patient became hypotensive and lost pulses. Point-of-care ultrasound revealed cardiac tamponade. TXA was immediately given to inhibit fibrinolysis since cryoprecipitate and blood products were not immediately available. Pericardiocentesis was performed and successfully removed 200 milliliters of blood with return of pulses. Clinicians must consider TXA as a rapidly accessible antagonist of tPA’s fibrinolytic effects.