Intravenous thrombolysis in stroke after dabigatran reversal with idarucizumab: case series and systematic review

Giannandrea, David; Caponi, Carla; Mengoni, Anna; Romoli, Michele; Marando, Claudia; Gallina, Antongiulio; Marsili, E; Sacchini, Elisa; Mastrocola, Sara; Padiglioni, Chiara; Mazzoli, Tatiana; Cenciarelli, Silvia; Ricci, Stefano

doi:10.1136/jnnp-2018-318658

Cited by 39 publications

(33 citation statements)

References 28 publications

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“…Opposing data was reported by Nakase et al, who found a higher NIHSS score in AIS while on a NOAC compared to VKA [29]. In patients qualifying for intravenous thrombolysis (IVT) or endovascular therapy (EVT), NIHSS score values were overall high, but roughly equal with NOAC and VKA pretreatment respectively [30–33].…”

Section: Resultsmentioning

confidence: 98%

“…In the biggest case series including 55 patients, IVT after dabigatran reversal was feasible with a symptom onset to needle time of 175 minutes [33]. Furthermore, its use was effective with a mean clinical improvement seen in 82% of the patients (6.3 points difference in NIHSS) and a follow-up mRS <2 in 56% of patients.…”

Section: Resultsmentioning

confidence: 99%

“…Following the AIE, switching temporarily to low molecular weight heparin was preferred by some authors [14], whereas most authors preferred switching to another NOAC with a different mechanism of action [40] for long-term prophylaxis. However, sometimes restarting the same NOAC was favored—possibly due to the good outcome of AIE on dabigatran and the possibility of antagonizing its effect by idarucizumab [33,54,64]. Also, a change of VKA was reported [14].…”

Section: Resultsmentioning

confidence: 99%

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Clinical presentation, diagnostic findings and management of cerebral ischemic events in patients on treatment with non-vitamin K antagonist oral anticoagulants – A systematic review

et al. 2019

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Background Non-vitamin K antagonist oral anticoagulants (NOAC) are equally or potentially superior in terms of effectiveness in the prevention of ischemic stroke and carry a lower associated risk of intracranial hemorrhage compared to Vitamin K antagonists. Nevertheless, ischemic strokes also occur in patients who are being treated with NOAC. In those particular patients, knowledge about the underlying stroke etiology, clinical presentation, acute management, and complication rates is scarce. Objective Systematic literature review to provide a comprehensive clinical overview in terms of presentation, laboratory, imaging parameters and outcomes of patients suffering from acute cerebral ischemic events (i.e. TIA and acute ischemic stroke) while on treatment with a NOAC. Only if available, comparison to VKA is presented which was not the primary focus of this analysis. Data sources PubMed/MEDLINE, Scopus and EMBASE from January 1, 2006, to November 20, 2018. Study eligibility criteria 52 studies providing detailed information on a total of 12247 patients were included. We excluded case reports and case series with less than five patients. Study appraisal and synthesis method We systematically assessed study quality using a bias tool and pooled consistent data. Results Existing data indicates milder stroke severity and smaller infarct size of acute ischemic stroke on treatment with NOAC compared to stroke occurrence on Vitamin K antagonists (VKA). Established risk factors for ischemic events also play a role in stroke while on NOACs, albeit the underlying etiology remains poorly understood. Intravenous thrombolysis and endovascular therapy seem to be safe and effective, but patient selection for recanalization therapies is challenging. Limitations Limited quality of published data, duplicate cases, statistical issues of data pooling, possible incomplete retrieval of identified research and reporting bias might have limited our findings. Conclusions Acute ischemic events despite treatment with NOAC therapy are insufficiently investigated. Systematic review registration number PROSPERO: CRD42018074853.

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Section: Resultsmentioning

confidence: 98%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Clinical presentation, diagnostic findings and management of cerebral ischemic events in patients on treatment with non-vitamin K antagonist oral anticoagulants – A systematic review

et al. 2019

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“…It is expected to be improved in similar cases. In a Franch retrospective research, patients with acute ischemic stroke who were treated with dabigatran within 48 hours were recommended for intravenous thrombolysis after idarucizumab's reversal without direct prothrombin activity monitoring [9] .Giannandrea [10] reviewed 55 thrombolytic cases after idarucizumab reversal of dabigatran showed that 81.9% (45 cases) of patients had improved NIHSS score (median 5 points). In a retrospective study of 120 patients with acute ischemic/hemorrhagic stroke in Germany, the e cacy and safety of idarucizumab reversal of dabigatran in intravenous thrombolysis with acute ischemic stroke had been con rmed.However, in patients with hemorrhagic stroke, the application of can prevent the expansion of hematoma and improve the prognosis of patients [11] .…”

Section: Discussionmentioning

confidence: 99%

Intravenous Thrombolysis after Reversal of Dabigatran with Idarucizumab in Acute Ischemic Stroke: A Case Report

Xie¹,

Wang²,

Li³

et al. 2020

Preprint

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Background: As there is a growing concern about the cerebral embolism events secondary to non-valvular atrial fibrillation, direct oral anticoagulant (DOAC) has been more and more widely used as an anticoagulation treatment for prevention of stroke. However, in the face of life-threatening bleeding or emergency surgery/treatment, doac-related antagonists such as idarucizumab need to be urgently used to reverse the DOAC. Using rt-PA intravenous thrombolysis for acute ischemic stroke requires a time window of 4.5 hours. This case reports rt-PA intravenous thrombolysis after reversal of dabigatran anticoagulation with idarucizumab in patients with acute ischemic stroke. Case presentation: We report the case of 62-year-old Chinese female with nonvalvular atrial fibrillation treated with dabigatran 110mg twice daily, and missed a dose on the eve of the stroke. The patient presented with acute ischemic stroke causing the angle of mouth deviated to right side and left limb weakness in the early morning of the next day. Due to the last dosing time of dabigatran was between 24-48 hours, the patients were given rt-PA intravenous thrombolysis after reversal of dabigatran anticoagulation with idarucizumab, while all contraindications had been excluded by laboratory test and CT scan. NIHSS score was reduced from 4 to 1, and the patient was discharged after 2 weeks. Conclusion: Our case report adds to the evidence that idarucizumab administration is safe and effective in the setting of patients with atrial fibrillation treated with dabigatran who develop acute ischemic stroke requiring rt-PA intravenous thrombolysis.

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“…In a recent systemic review by Giannandrea et al ,11 55 cases of patients who met inclusion criteria were included for analysis. Of these, 81.9% (n=45) of patients had favourable outcomes with page 4 of 10 thrombolysis after dabigatran reversal, with an improvement of median NIHSS score by 5 points.…”

Section: Discussionmentioning

confidence: 99%

Successful thrombolysis for acute ischaemic stroke after reversal of dabigatran etexilate with idarucizumab

Loh¹,

Herkes

2019

BMJ Case Rep

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We report the experience of reversing dabigatran prior to administering systemic thrombolysis for acute ischaemic cerebellar stroke, which was well tolerated with no haemorrhagic complications after thrombolysis. Given the increasingly common use of dabigatran for atrial fibrillation, the use of idarucizumab to reverse of dabigatran is a novel treatment that should be considered as an important adjunct to facilitate thrombolysis for ischaemic strokes and minimise haemorrhagic complications.

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Intravenous thrombolysis in stroke after dabigatran reversal with idarucizumab: case series and systematic review

Cited by 39 publications

References 28 publications

Clinical presentation, diagnostic findings and management of cerebral ischemic events in patients on treatment with non-vitamin K antagonist oral anticoagulants – A systematic review

Clinical presentation, diagnostic findings and management of cerebral ischemic events in patients on treatment with non-vitamin K antagonist oral anticoagulants – A systematic review

Intravenous Thrombolysis after Reversal of Dabigatran with Idarucizumab in Acute Ischemic Stroke: A Case Report

Successful thrombolysis for acute ischaemic stroke after reversal of dabigatran etexilate with idarucizumab

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