ISCHEMIC STROKE / ACUTE THERAPY

Recanalization therapy in anticoagulated patients

Created 11/11/2021, last revision 18/04/2022

Intravenous thrombolysis

Warfarin
  • INR ≤ 1.7 IVT can be given within a 4.5h window, 2 larger studies and data from the registry of nearly 24,000 patients have not shown an increased risk of bleeding with INR < 1.7 (ESO guidelines, 2021) [Xian, 2012]
  • INR > 1.7 or unknown INR ⇒ no IVT   (ESO guidelines, 2021)
  • NR > 1.7 + administration of 4F-PCC followed by thrombolysis ⇒ could be safe according to small studies; randomized trials are not available
    • prothrombin complex concentrates may enhance coagulation with worsening of patients’ neurological deficits
    • a clear recommendation cannot be made   [Chausson, 2018]
Heparin / LMWH
  • LMWH at a prophylactic dose is not a contraindication; IVT appears safe and is not associated with a higher risk of sICH  (Cooray, 2019]
  • Contraindications to IVT:
    • aPTT exceeding the upper limit of normal laboratory values (>40s)
    • full (therapeutic) dose of LMWH administered < 24h
  • not much data on the safety of IVT after Protamine administration; there is a risk of progression of ischemia ⇒ prefer direct MT
Dabigatran (PRADAXA)
  • intravenous thrombolysis (IVT)  in patients with acute ischemic stroke is possible with dabigatran therapy if aPTT + TT, ECT, or HEMOCLOT values do not exceed the upper limits of the reference values  (AHA/ASA 2013 III/C)
    • normal aPTT alone is not sufficient; it does not entirely rule out elevated TT  [Kermer, 2017] [Hankey, 2014]
    • IVT can be considered in patients with normal TT or TT <60 s and normal APTT   (ESO guidelines 2021)

      • expert opinion, no sufficient evidence to make an evidence-based recommendation
    • Hemoclot – a dabigatran level < 50 ng/ml > 6h after the last dose of the drug indicates the absence of anticoagulant activity
  • administration of thrombolysis after prior neutralization of the effect of dabigatran with the antidote PRAXBIND is possible (indications for Praxbind include emergency procedures, which may include thrombolysis)
    • according to expert consensus, the combination of idarucizumab and IVT is suggested for patients with acute ischemic stroke of <4.5 h duration   (ESO guidelines 2021)   [Diener, 2017]
    • according to registry data, administration of the antidote PRAXBIND in patients with acute stroke followed by thrombolysis is effective, safe, and easy to perform [Kermer, 2017]
Xabans (ELIQUIS, XARELTO, LIXIANA)
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Mechanical recanalization

  • in mechanical thrombectomy (MT), the use of anticoagulants or thrombocytopenia are not a contraindication to the procedure; the benefit is clear in proximal occlusions
    • MT can be performed in patients using DOACs without antidote administration [Diener, 2017]
  • some data suggest, there is a higher risk of sICH and higher mortality in patients using warfarin (not DOACs)  [Meinel, 2020]
  • MT cannot be combined with IA thrombolysis in patients on anticoagulant therapy
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