ISCHEMIC STROKE / ACUTE THERAPY
Recanalization therapy in anticoagulated patients
Created 11/11/2021, last revision 06/11/2023
- ischemic stroke may occur despite anticoagulation due to subtherapeutic anticoagulation, non-compliance, or a prothrombotic condition that increases the clotting risk despite anticoagulation
- anticoagulants complicate the decision-making process for thrombolysis and mechanical thrombectomy in acute ischemic stroke
- iIt’s crucial to weigh the potential benefits against the risks and consider the timing of the last DOAC dose and the availability of reversal agents
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 six stroke patients otherwise eligible for IVT uses DOACs
- guidelines recommend excluding 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 might be safe for patients on DOACs
- according to a cohort study and a meta-analysis, IVT does not lead to an increased incidence of sICH in selected patients on 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 who have recently used DOACs
Mechanical recanalization (thrombectomy)
- the use of anticoagulants or thrombocytopenia is not a contraindication to mechanical thrombectomy (MT); the benefit is evident for proximal occlusions
- MT may be performed on patients taking DOACs without administering an antidote [Diener, 2017]
- in patients on dabigatran, the administration of idarucizumab may be considered
- in the setting of thrombocytopenia, the procedure’s risks and benefits must be carefully evaluated; consider transfusing platelets to increase the count, especially if the count is below a critical threshold (e.g., <50,000/µL, though the exact threshold is not established)
- some data suggest that patients on warfarin (not DOACs) face a higher risk of sICH and increased mortality [Meinel, 2020]
- intensive monitoring in a neurocritical care setting is vital after the procedure to detect any early signs of intracranial hemorrhage