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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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