Human fibrinogen concentrate Fibryga® enables rapid reversal of thrombolysis and timely repair of acute Stanford type A aortic dissection: a case report

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Background: Acute Stanford type A aortic dissection (ATAAD) may mimic acute ischaemic stroke (AIS), occasionally resulting in administration of thrombolytics and potentially leading to life-threatening haemorrhage. Rapid recognition and reversal of thrombolysis-associated coagulopathy are essential to permit timely surgery. Case summary: A 53-year-old man with history of poorly controlled hypertension presented with acute right-sided hemiparesis, aphasia, and dysarthria. AIS was suspected, and intravenous tenecteplase (TNK) was administered once intracranial haemorrhage was ruled out on non-contrast head computerized tomography (CT) scan. Shortly after thrombolysis, CT angiogram revealed an ATAAD with occlusion of the left common carotid artery, significant compression of true lumen, and involvement of both femoral arteries. TNK was immediately reversed with cryoprecipitate and human fibrinogen concentrate (Fibryga®), raising fibrinogen level within an hour from 102 to 234 mg/dL, thereby enabling timely emergent repair of acute type A dissection. Despite a complicated intra- and post-operative course that included cardiac arrest secondary to rupture and haemopericardium, acute kidney injury, and bowel perforation, the patient was discharged to rehabilitation facility with favourable neurological function. Discussion: This case illustrates the diagnostic pitfall of ATAAD presenting as stroke and highlights the utility and safety of fibrinogen concentrate (Fibryga®) in rapid reversal of thrombolysis-associated coagulopathy, allowing for safe and timely surgical intervention for ATAAD.

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