How to approach reversal of TNK in hemorrhagic conversion of ischemic stroke?

There is no specific "reversal agent" for tenecteplase. Once administered, the thrombolytic effect will persist until the drug is fully metabolized and any residual plasmin has been cleared by alpha-2-antiplasmin. So, perhaps the first question is what can you do if there is an acute bleeding event after administration of tenecteplase?

Tenecteplase does not result in systemic fibrinogen depletion to any great degree. In contrast, a significant minority of patients treated with intravenous alteplase will get systemic fibrinogen depletion. Thus, with alteplase-associated acute hemorrhage, it makes sense to consider giving fibrinogen replacement. This can be done with RiaSTAP (Fibrinogen concentrate) preferably since you neither have to admini...

To summarize (in addition to such a thorough answer above) we follow the same reversal protocol for TNK that is outlined in the AHA/ASA acute ischemic stroke guidelines (most recent 2018, rev 2019) for tPA. The mechanism of action of both are similar. TNK has a longer half-life and greater fibrin specificity than tPA). Here checking fibrinogen levels after initial reversal steps will be a great guide to deciding whether to repeat or potentially use aminocaproic acid or tranexamic acid.