Intravenous thrombolysis in acute ischemic stroke after dabigatran etexilate reversal with idarucizumab

Abstract

Background: Intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (rt-PA) for
acute ischemic stroke treatment is contraindicated in patients who are actively taking either Factor Xa
inhibitors or direct thrombin inhibitors. Idarucizumab completely reverses the biologic effect of dabigatran
within minutes.
Case Presentation: Hereby, we present the case of a 65 old male on active dabigatran treatment with
a severe acute ischemic stroke and otherwise eligible for rt-PA treatment. Idarucizumab was administered
and the patient was subsequently treated with IV rt-PA. Despite the IVT, the patient’s clinical condition deteriorated and he developed a left middle cerebral artery territory infarct with hemorrhagic transformation.
Conclusion: Recently intravenous rt-PA has been suggested as a treatment in acute ischemic stroke patients anticoagulated with dabigatran after the reversal with idarucizumab. There are little reported data and no large scale studies of the efficacy and safety of IVT after dabigatran reversal. Further studies and
register data are needed to provide additional information regarding the antidotes and the use of rt-PA