Fibrinogen Depletion in Stroke Patients Under Bridging Therapy Increases Bleeding and Mortality Risk: Study

A new study published in the Stroke journal revealed a crucial link between early fibrinogen depletion coagulopathy (FDC) and an increased risk of hemorrhagic complications and death in stroke patients undergoing combined intravenous thrombolysis (IVT) and endovascular therapy (EVT), commonly referred to as bridging therapy.

This study involved 296 patients with acute ischemic stroke and large vessel occlusion evaluated the impact of FDC on hemorrhagic transformation (HT) and patient outcomes. FDC was defined as a sharp drop in fibrinogen levels, below 2.0 g/L at the start of EVT, coupled with a decrease of more than 1.0 g/L from baseline.

Among the cohort, 102 patients (34.5%) developed HT within 24 to 36 hours, while 54 (18.2%) expressed FDC. Also, FDC was almost exclusively seen in patients who received IVT, especially those treated with alteplase, highlighting a potential adverse effect of this thrombolytic agent.

Any hemorrhagic transformation was more than twice as likely in patients with FDC (adjusted odds ratio [aOR] 2.33). Symptomatic HT was over three times more likely (aOR 3.35). Parenchymal hematomas, a severe form of bleeding in the brain, were nearly three times more common (aOR 2.87). Three-month mortality was markedly higher among patients with FDC, with nearly a fourfold increase in odds (aOR 3.82).

The analysis illuminated a strong difference between alteplase and tenecteplase. FDC was identified in 39.3% of patients treated with alteplase (53 of 135), but none of the 26 patients who received tenecteplase developed this coagulopathy, suggesting a potentially safer profile for tenecteplase in terms of fibrinogen preservation.

Also, IVT was found to be a strong predictor of FDC: 32.9% of IVT-treated patients developed FDC when compared to just 0.7% of those who underwent EVT alone. These findings raised important considerations regarding the type and use of thrombolytics in bridging therapy protocols.

Overall, the study suggested that early monitoring of fibrinogen levels and careful selection of thrombolytic agents, particularly favoring tenecteplase over alteplase, may help reduce bleeding complications and improve survival rates in this high-risk population.

Reference:

Pauillac, N., Faille, D., Solo Nomenjanahary, M., Souvanheuane, M., Brikci-Nigassa, N., Ameri, A., Benoit, T., Delvoye, F., Maier, B., Ho-Tin-Noé, B., Mazighi, M., Desilles, J.-P., Seners, P., & NEUTROSTROKE study group. (2025). Fibrinogen depletion coagulopathy and hemorrhagic transformation in acute ischemic stroke treated with bridging therapy. Stroke; a Journal of Cerebral Circulation. https://doi.org/10.1161/STROKEAHA.125.051230