Myoclonus associated with tranexamic acid administration in a patient on veno-arterial extracorporeal membrane oxygenation support: A case report

Table 1 Clinical timeline and key events

Time course	Clinical status/findings	Interventions
Day 0	STEMI complicated by cardiogenic shock; LVEF 15%-20%; LAD and RCA 100% occlusion	Primary PCI to LAD; inotropes and vasopressors; IABP insertion
Day 1	Hemodynamic instability despite maximal medical therapy	Transfer to tertiary center; VA-ECMO implantation; UFH anticoagulation
Day 7	Progressive thrombocytopenia (> 50% drop)	Diagnosis of HIT; UFH discontinued; switch to argatroban
Day 8	Rising ECMO oxygenator transmembrane pressures; thrombus formation; elevated D-dimers (> 35000 ng/mL); declining fibrinogen	Intravenous tranexamic acid 1 g twice daily
Day 9	Generalized myoclonic movements; mild confusion; normal brain CT and metabolic profile	Neurological consultation; exclusion of alternative causes/suspected TXA-induced neurotoxicity
Days 9-10	Cumulative TXA dose 3 g in setting of CRRT	Discontinuation of TXA- complete resolution of myoclonus within 48 h
Day 23	Time for VA-ECMO decannulation	Durable LVAD implantation
Follow-up	Stable clinical status; good LVAD function; good quality of life	Regular outpatient follow-up

STEMI: ST-elevation myocardial infarction; LAD: Left anterior descending; VA-ECMO: Veno-arterial extracorporeal membrane oxygenation; UFH: Unfractionated heparin; ECMO: Extracorporeal membrane oxygenation; CT: Computed tomography; TXA: Tranexamic acid; CRRT: Continuous renal replacement therapy; LVAD: Left ventricular assist device; LVEF: Left ventricular ejection fraction; RCA: Right coronary artery; PCI: Percutaneous coronary intervention; IABP: Intra-aortic balloon pump; HIT: Heparin-induced thrombocytopenia.