Emergency Craniotomy After Alteplase Administration

Preoperative Reversal Protocol

The American Heart Association recommends administering 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
Cryoprecipitate contains factor VIII and fibrinogen, with an onset of action in 1 hour, peaking at 12 hours, and should be given in additional doses if fibrinogen level remains <200 mg/dL 1

Before proceeding to surgery, obtain a complete blood count (CBC), prothrombin time (PT/INR), activated partial thromboplastin time (aPTT), fibrinogen level, and type and cross-match for packed red blood cells 1
Ensure immediate availability in the operating room of multiple units of packed red blood cells (cross-matched), additional cryoprecipitate units on standby, fresh frozen plasma (FFP) if INR becomes elevated, and platelets if count drops below 100,000/mm³ [1] [3]

Maintain optimal conditions for hemostasis by managing blood pressure (avoiding hypertension), monitoring and controlling intracranial pressure, optimizing cerebral perfusion pressure, controlling temperature (avoiding hyperthermia), and controlling glucose levels (avoiding hyperglycemia) 1

Immediate neurosurgery consultation is mandated by AHA guidelines for any bleeding complication after alteplase, and hematology consultation should also be obtained 1