Background: American Heart Association suggests empirical therapies (cryoprecipitate, FFP and platelets) for post-IVtpa hemorrhage but acknowledges the lack of evidence to support any specific therapy. Different institutions have developed care pathways for post-IVtpa sICH involving frequent fibrinogen level checks. During thrombolysis, circulating fibrinogen is decreased, and thus rapid administration of cryoprecipitate is recommended. A marker of fibrinogen of <100-150 mg/dL has been traditionally used as a cutoff to suggest effective thrombolysis or administration of cryoprecipitate or to assess the risk of bleeding complications. Monitoring of fibrinogen level has been used to guide the reversal therapy in the setting of post-IVtpa hemorrhage. This practice is not fully addressed in the literature.
Purpose: To determine the significance of fibrinogen level in relation to thrombolysis in acute ischemic stroke (AIS) based on our single center experience.
Methods: We retrospectively reviewed fibrinogen levels in two groups of patients with AIS who presented to our comprehensive stroke center. First group included 50 patients who received IVtpa including two patients w/ post-IVtpa sICH and second group included 50 patients with AIS who could not receive IVtpa due to contraindication. Fibrinogen level was checked in immediate post-IVtpa period usually within 2hr of IVtpa or 6hr from onset.
Results: The mean fibrinogen level in first group with patients with AIS who received IVtpa is 321.65 mg/dl with range from 102 to 533 mg/dl. Normal reference range is 220-410mg/dl. The mean fibrinogen level in second group without IVtpa is 376mg/dl with range from 124 to 583mg/dl. The fibrinogen level in two patients with post-IVtpa sICH was 216 and 282 mg/dl.
Conclusions: No significant correlation is found between fibrinogen level (<100mg/dl) and IVtpa use. We also found no significant change in fibrinogen level in patients with post-IVtpa sICH even though there are only two cases included so far. Above finding suggests that we should focus our research on mechanism other than decrease fibrinogen level to be an underlying cause of post-IVtpa hemorrhage in order to develop agent for better reversal and to prevent continued hematoma expansion.