ISCHEMIC STROKE / ACUTE THERAPY
Recanalization therapy in anticoagulated patients
Created 11/11/2021, last revision 25/04/2023
Intravenous thrombolysis
- in general, intravenous thrombolysis (IVT) is contraindicated in patients who are effectively anticoagulated (due to the presumed increased risk of ICH)
- with the use of DOACs, this contraindication has become somewhat relative
Intravenous thrombolysis in DOAC-treated patients
- since the shift from vitamin K antagonists (VKAs) to DOACs, it is estimated that every sixth patient with a stroke otherwise eligible for IVT uses DOACs
- guidelines recommend to exclude stroke patients with recent use of DOACs (< 48 hours) from receiving IVT (except for dabigatran, where idarucizumab can be used)
- this recommendation was based on the presumption of an increased risk of symptomatic intracranial hemorrhage (sICH)
- this recommendation was based on the presumption of an increased risk of symptomatic intracranial hemorrhage (sICH)
- recent data suggest that IVT may also be safe in patients taking DOACs
- according to both a cohort study and a meta-analysis, IVT does not lead to an increased incidence of sICH in selected patients taking DOACs (Kam, 2022) (Shahjouei,2019)
- DOAC-IVT trial (2023) also showed insufficient evidence of excess harm associated with off-label IVT in selected ischemic stroke patients with recent DOAC use
Mechanical recanalization (thrombectomy)
- the use of anticoagulants or thrombocytopenia is no contraindication to mechanical thrombectomy (MT); the benefit is clear for proximal occlusions
- MT may be performed in patients on DOACs without antidote administration [Diener, 2017]
- some data suggest that patients on warfarin (not DOACs) have a higher risk of sICH and increased mortality [Meinel, 2020]
- MT should not be combined with IA thrombolysis in patients on anticoagulant therapy