Successful thrombolysis with recombinant tissue plasminogen activator after antagonizing dabigatran by idarucizumab: a case report

Abstract

BackgroundEffective anticoagulation routinely precludes patients from receiving intravenous thrombolysis with recombinant tissue plasminogen activator to reverse severe symptoms of ischemic stroke. We report what we believe to be the first case of ischemic stroke successfully treated with recombinant tissue plasminogen activator after antagonizing dabigatran with the monoclonal antibody idarucizumab, recently approved worldwide.Case presentationA 75-year-old Caucasian man presented to our hospital with severe aphasia and mild hemiparesis. After providing written consent, he received two doses of 2.5 g of idarucizumab over 20 minutes followed by standard protocol in-label recombinant tissue plasminogen activator application. All symptoms resolved within 1 h.ConclusionsApplying a recombinant tissue plasminogen activator after antagonizing dabigatran with idarucizumab is feasible and easy to manage in an emergency room or stroke unit. Thus, idarucizumab represents a new therapeutic option for patients receiving dabigatran treatment, reestablishing their eligibility for recombinant tissue plasminogen activator thrombolysis.

Idarucizumab in Dabigatran-Treated Patients with Acute Ischemic Stroke Receiving Alteplase: A Systematic Review of the Available Evidence

“…Dabigatran etexilate is a prodrug of dabigatran. Dabigatran inhibits the function of thrombin, which stabilizes clots by catalyzing the conversion of fibrinogen to fibrin [ 9 ]. Severe hemorrhagic complications, similar to those seen with vitamin K antagonists, can be anticipated in the context of tPA treatment in patients receiving anticoagulation treatment with dabigatran, and, in fact, a case of fatal intracerebral hemorrhage has been reported among seven tPA-treated patients also receiving dabigatran [ 10 , 11 ].…”

Alteplase for Acute Ischemic Stroke after Heparin Reversal with Protamine: A Case Report and Review

“…These situations introduce an additional layer of complexity given the underlying thrombotic disease states present, which was not necessarily the case with our patient. Cases where ongoing therapeutic anticoagulation with dabigatran was reversed with idarucizumab to facilitate alteplase administration have been reported . In each of these cases the patients were receiving therapeutic anticoagulation for stroke prevention in atrial fibrillation .…”

“…Cases where ongoing therapeutic anticoagulation with dabigatran was reversed with idarucizumab to facilitate alteplase administration have been reported. [15][16][17][18] In each of these cases the patients were receiving therapeutic anticoagulation for stroke prevention in atrial fibrillation. [15][16][17][18] In all four cases, feasibility of alteplase administration was established with the potential for clinical improvement and without evidence of ICH.…”

Intravenous thrombolysis for acute ischaemic stroke in patients on direct oral anticoagulants

“…The use of idarucizumab may therefore be discussed if dabigatran has been taken recently and/or if the dabigatran plasma level is high enough to contraindicate IVT in the absence of any alternative. More recently, several observations of IVT following administration of idarucizumab have been reported, with no haemorrhagic or thrombotic complications [35][36][37][38][39][40][41][42][43][44]. A recent expert opinion statement has provided guidance on the use of the specific reversal agent idarucizumab followed by rtPA and/or thrombectomy [12].…”