Acute thrombocytopenia from alteplase in a patient with stroke

Abstract

Alteplase, a recombinant tissue plasminogen activator (rtPA), is a standard thrombolytic therapy for acute ischemic stroke. Although generally safe, it can cause complications such as hemorrhagic transformation, intracranial hemorrhage, gastrointestinal hemorrhage, and angioedema. Acute thrombocytopenia has rarely been reported after rtPA administration. Awareness of this adverse reaction is essential for timely management.

In this case report, a 69-year-old Thai male with no known underlying diseases developed sudden-onset left hemiparesis, left upper motor neuron facial palsy, and dysarthria. At a general hospital, his non-contrast CT brain scan showed a hypodense lesion in the right frontoparietotemporal region with an Alberta stroke programme early CT score (ASPECTS) of 4. The diagnosis was right MCA infarction. Thrombectomy was not performed due to the poor ASPECTS. He received a standard dose of rtPA. His platelet count was 205,900/µL on admission, and his PT and PTT were normal. Forty-eight hours later, the patient developed an altered level of consciousness. A non-contrast CT brain was repeated, and the result showed progressive brain swelling without bleeding, so he was intubated and transferred to King Narai Hospital for decompressive craniectomy. Sixty-one hours after rtPA was administered (before surgery), his platelet count decreased to 25,000/µL and his PT and PTT were normal. He exhibited no signs of bleeding. Thrombocytopenia was confirmed on repeat evaluation using a citrate tube, with a platelet count of 42,000/µL without evidence of platelet clumping. Intermittent platelet concentrate transfusions were given. Eight days after rtPA administration, his platelet count returned to the normal range, and no further platelet transfusion was needed. The proposed mechanism of thrombocytopenia was drug-induced.