2026 Eastern States Conference

Evaluation of hemorrhagic conversion and use of fibrinogen products after fibrinolytic therapy for acute ischemic stroke 

Authors
Norah Albanyan PharmD; Nihad Medar PharmD, BCCCP; Patricia Cyrus PharmD, BCPS; Melanie Goodberlet PharmD BCPS, BCCCP; Skyler Starkel PharmD, BCCCP

Learning Objective
Describe the differences in hemorrhagic conversion and bleeding outcomes between tenecteplase (TNK) and alteplase (tPA) in acute ischemic stroke.

Self-Assessment Question 
In this retrospective cohort study comparing tPA and TNK for acute ischemic stroke, what was observed regarding intracranial hemorrhagic (ICH) conversion within 24 hours?

A. TNK was associated with a significantly higher rate of ICH
B. tPA was associated with a significantly higher rate of ICH
C. There was no statistically significant difference in ICH between tPA and TNK
D. TNK eliminated the risk of ICH compared to tPA

Background /objective
Acute ischemic stroke (AIS) is a leading cause of morbidity and mortality. Alteplase (tPA) or tenecteplase (TNK) are used to improve outcomes. This study compares incidence of hemorrhagic conversion and use of fibrinogen products following tPA or TNK

Method
This was a single-center retrospective cohort study at a tertiary academic medical center approved by the Mass General Brigham Institutional Review Board (2025P002247). Adult patients (≥18 years) with AIS treated with tPA or TNK between January 2020 and October 2025 were included. Our institution transitioned to TNK as the preferred fibrinolytic agent for AIS in June 2023. Patients were excluded if 24-hour post-treatment neuroimaging was unavailable or thrombolytic dosing was outside guideline recommendations

The major outcome was intracranial hemorrhagic conversion within 24 hours. Minor outcomes included extracranial bleeding, time to hemorrhagic conversion, post-lysis fibrinogen levels, fibrinogen product use, and 30-day mortality. Categorical outcomes were compared using chi-square or Fisher’s exact tests, continuous variables using t-test or Mann–Whitney U test. A multivariable logistic regression identified independent predictors of hemorrhagic conversion.

Results
A total of 114 patients met eligibility, 55 (48.2%) received TNK and 59 (51.8%) tPA. Hemorrhagic conversion within 24 hours occurred in 6 patients in the TNK group and 7 in the tPA (10.9% vs 11.8%, p=0.87). There was no difference in time to hemorrhagic conversion, extracranial bleeding within 24 hours, or mortality between groups. Replacement with fibrinogen products was only seen in the tPA group (4 patients). Median fibrinogen at hemorrhagic conversion 381 mg/dL (TNK) vs 138.5 mg/dL (tPA). When controlling for confounders, a higher National Institutes of Health Stroke Scale score was associated with hemorrhagic conversion.

Conclusion  
In this retrospective cohort of patients with AIS, TNK and tPA had similar rates of hemorrhagic transformation, extracranial bleeding, and 30-day in-hospital mortality, suggesting comparable bleeding safety profiles between the two agents in our cohort. Notably, fibrinogen product use was observed only in the tPA group, which had lower fibrinogen levels. Further research is needed to better define optimal reversal strategies for these agents.