Reversal of dabigatran using idarucizumab: single center experience in four acute stroke patients

Abstract

Dabigatran is a direct thrombin inhibitor and a non-vitamin-K-antagonizing oral anticoagulant, approved for the prevention of stroke and systemic embolization in atrial fibrillation. Idarucizumab is a humanized monoclonal antibody that was recently approved for antagonizing the anticoagulant effects of dabigatran. Here, we report the use of idarucizumab in four acute stroke patients treated with dabigatran in order to enable intravenous thrombolysis in three patients and emergent trepanation in one patient with space occupying subdural hematoma. Since experience on the optimal management of acute stroke patients under medication with dabigatran and on the use of idarucizumab is currently limited, we propose an approach for laboratory testing and fast administration of intravenous thrombolysis and neurosurgery based on our experience.

Intravenous Thrombolysis After Dabigatran Reversal by Idarucizumab: A Systematic Review of the Literature

“…Among 463 articles identified from the initial literature search, 49 studies including 251 patients were eligible and included in the analysis ( 1 , 13 – 57 , 60 – 63 ) ( Figure 1 ). Forty-five studies provided individual patient data of 119 AIS patients ( 13 – 23 , 25 , 27 – 36 , 38 – 57 , 60 – 63 ), whereas four case-series reported results on overall 151 patients ( 1 , 24 , 26 , 37 ).…”

Antagonizing dabigatran by idarucizumab in cases of ischemic stroke or intracranial hemorrhage in Germany—Updated series of 120 cases

“…11,12 To date, data on the use and clinical effectiveness of idarucizumab in patients with intracranial bleeding or acute ischemic stroke under dabigatran treatment are limited to single case reports, [13][14][15][16][17] small case collections, [18][19][20] or review articles. [21][22][23][24][25][26]…”

Immediate Reversal of Dabigatran by Idarucizumab Prior to Laboratory and Imaging Results in Acute Stroke

“…Here, we report the case of a patient under medication with dabigatran with acute ischemic stroke, who received idarucizumab and subsequently intravenous thrombolysis. In contrast to formerly reported cases (11, 13, 14), here, we explicitly refrained from awaiting the results of (i) the thrombin time (TT), as a marker for present anticoagulation by dabigatran and (ii) the cerebral imaging before administration of idarucizumab to minimize door-to-needle time and thus to enhance the chance for a good outcome. The decision for the application of idarucizumab was based on anamnesis and clinical examination only.…”

“…Despite exclusion of this indication in the original pivotal study of idarucizumab (3), several recent case reports and series provide increasing evidence, that reversal of dabigatran by idarucizumab followed by intravenous thrombolysis in acute ischemic stroke is effective and safe (8, 9). However, large randomized controlled trials on this topic are lacking, and the optimal management and diagnostic work flow of this approach is still under discussion (10, 11).…”