B64-45 From Local to Systemic: Ischemic Stroke Following Nebulized Tranexamic Acid

Introduction Tranexamic acid (TXA) is an antifibrinolytic agent that inhibits fibrinolysis by blocking the lysine-binding sites on plasminogen. It has been shown to decrease mortality from hemorrhagic shock in trauma and childbirth. Although some studies have suggested a possible association between intravenous TXA and venous thromboembolisms, this relationship remains unclear. Nebulized TXA is indicated in the treatment of hemoptysis with minimal systemic absorption. We report a case of ischemic stroke following administration of nebulized TXA for diffuse alveolar hemorrhage in the setting of hepatopulmonary syndrome, possibly due to systemic absorption of TXA from intrapulmonary shunting. Case A 49-year-old man with ILD and chronic hypoxemic respiratory failure, COPD, and alcoholic liver cirrhosis, presented with acute on chronic hypoxic respiratory failure. An echocardiogram with bubble study revealed an intrapulmonary shunt, which, in the setting of cirrhosis, raised concern for hepatopulmonary syndrome. Bronchoalveolar lavage confirmed diffuse alveolar hemorrhage (DAH) with rising BAL RBC count (from 3000 RBCs/µL to 14,000 RBCs/µL to 27,000 RBCs/µL), likely secondary to coagulopathy from liver cirrhosis (platelet count 45 x 103/µL, INR 1.4). When on maximal high flow nasal cannula therapy (100%, 40L) with persistent drops in SpO2, he was started on nebulized TXA for DAH at 500 mg TID. Following administration of nebulized TXA his oxygen requirement decreased to 6L NC. Approximately twelve hours after initiation of TXA, he was noted by nursing staff to have a headache and monocular vision loss in the right eye. Stat CTA of the head and neck demonstrated an acute ischemic stroke with occlusion of the right internal carotid artery, successfully managed with mechanical thrombectomy. The nebulized TXA was discontinued after ICA occlusion. The following day, he developed another CVA with complete right ICA occlusion, for which he again underwent thrombectomy with ICA stent placement. Of note, prophylactic anticoagulation had been held for one dose for a planned paracentesis prior to his second stroke. Discussion and Conclusion Our case represents a rare instance of a thrombotic event following nebulized, rather than systemic, TXA administration. The occurrence of stroke in this patient is likely multifactorial, given his critical illness and cirrhosis, with an intrapulmonary shunt that possibly facilitated systemic absorption of nebulized TXA. This case underscores the need for caution and further investigation into the safety of nebulized TXA, particularly in patients with hepatopulmonary syndrome or other shunting pathologies that could predispose to systemic drug absorption.