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Safety of Intravenous Thrombolysis among Stroke Patients Taking New Oral Anticoagulants--Case Series and Systematic Review of Reported Cases.

AbstractBACKGROUND:
Current guidelines do not recommend the administration of intravenous tissue plasminogen activator (IV-tPA) to patients with acute ischemic stroke (AIS) who take new oral anticoagulants (NOACs). We present a multicenter case series of IV-tPA use while the patients are on NOACs, as well as a systematic review of the literature.
METHODS:
We reviewed the medical records of consecutive patients on NOACs who received IV-tPA for symptoms of AIS at four participating stroke centers in the United States and Europe. Safety endpoints were post-thrombolysis symptomatic intracranial hemorrhage (sICH) or other serious systemic bleeding.
RESULTS:
Between October 2010 and October 2014, 6 patients received IV-tPA for possible AIS while taking dabigatran. None of the patients had sICH or any other hemorrhagic complication. Literature review resulted in a total of 26 patients receiving IV-tPA while on NOACs (dabigatran: 15, rivaroxaban: 10, apixaban: 1). Among them, two patients experienced sICH and died. None of the patients experienced major extracranial hemorrhage; however, minor and asymptomatic hemorrhagic complications were described in 7 patients. Pooled analysis indicates an sICH rate of 6.45% (95% CI by the adjusted Wald method: .8-21.7%). The mean interval between the last dose of NOAC and IV thrombolysis was 12 ± 7.8 [4-28.3] hours.
CONCLUSIONS:
Although the safety of IV-tPA cannot be definitively confirmed in a small series, consideration of stroke severity and management of hemorrhage risk with general precautions with post-tPA management protocols can justify treatment in the absence of coagulopathy.
AuthorsShima Shahjouei, Georgios Tsivgoulis, Reza Bavarsad Shahripour, G Morgan Jones, Andrei V Alexandrov, Ramin Zand
JournalJournal of stroke and cerebrovascular diseases : the official journal of National Stroke Association (J Stroke Cerebrovasc Dis) Vol. 24 Issue 12 Pg. 2685-93 (Dec 2015) ISSN: 1532-8511 [Electronic] United States
PMID26542821 (Publication Type: Case Reports, Journal Article, Review, Systematic Review)
CopyrightCopyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.
Chemical References
  • Anticoagulants
  • Fibrinolytic Agents
  • Tissue Plasminogen Activator
Topics
  • Aged
  • Aged, 80 and over
  • Anticoagulants (therapeutic use)
  • Brain Ischemia (drug therapy)
  • Female
  • Fibrinolytic Agents (adverse effects, therapeutic use)
  • Humans
  • Male
  • Middle Aged
  • Stroke (drug therapy)
  • Thrombolytic Therapy (adverse effects)
  • Tissue Plasminogen Activator (adverse effects, therapeutic use)
  • Treatment Outcome

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