Intravenous Thrombolysis after Reversal of Dabigatran by Idarucizumab: A Case Report

Abstract

We describe a 75-year-old female patient with nonvalvular atrial fibrillation who presented with acute ischemic stroke during treatment with dabigatran 2 × 110 mg per day. After informed consent, we reversed the anticoagulant effects of dabigatran using idarucizumab and applied an intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator (off-label use). An intracerebral hemorrhage was excluded after systemic thrombolysis. Despite the IVT, the patient’s clinical condition deteriorated and she developed an ischemic lesion in the right pons, the right thalamus and right cerebellum. To date, the literature lacks data concerning the thrombolytic treatment of acute ischemic stroke in patients after specific reversal of the non-vitamin K oral anticoagulant dabigatran using idarucizumab. Given the rapid and sustainable efficacy of idarucizumab, the reversal of dabigatran followed by thrombolysis seems to be safe, but further studies and register data are still needed to confirm our preliminary observation, especially to provide additional data concerning the risk-benefit evaluation.

Intravenous stroke thrombolysis after reversal of dabigatran effect by idarucizumab: first reported case in Hong Kong

“…2 As far as we know, there have been five case reports at the time of writing of this article, all from German centres, that have reported the successful use of idarucizumab for this indication; none had any haemorrhagic complications. 2,3 Four of these studies reported successful thrombolysis with good neurological recovery, whereas one study reported failed clinical improvement in a patient with infarcts in multiple territories. 3 Diener et al 4 have published an expert opinion on the management of these ischaemic strokes based on their experience in Germany.…”

“…2,3 Four of these studies reported successful thrombolysis with good neurological recovery, whereas one study reported failed clinical improvement in a patient with infarcts in multiple territories. 3 Diener et al 4 have published an expert opinion on the management of these ischaemic strokes based on their experience in Germany. They proposed that for patients who have taken dabigatran in the preceding 24 hours from the time of assessment (or 96 hours if the creatinine clearance is <30 mL/min), or for patients in whom time of last dabigatran dose is unknown and who have a prolonged APTT or TT, idarucizumab should be given if the patient is not a candidate for mechanical thrombectomy.…”

Alteplase for Acute Ischemic Stroke after Heparin Reversal with Protamine: A Case Report and Review

“…These situations introduce an additional layer of complexity given the underlying thrombotic disease states present, which was not necessarily the case with our patient. Cases where ongoing therapeutic anticoagulation with dabigatran was reversed with idarucizumab to facilitate alteplase administration have been reported . In each of these cases the patients were receiving therapeutic anticoagulation for stroke prevention in atrial fibrillation .…”

Direct Oral Anticoagulants and their Clinical Management

“…Idarucizumab (Praxbind), a monoclonal antibody, has been approved by the Therapeutic Good Administration (TGA) to reverse the anticoagulant activity of Dabigatran. 29 Idarucizumab specifically binds to Dabigatran, reversing its anticoagulant effect and is now approved by the TGA and available in Australia. Idarucizumab exhibited complete reversal of Dabigatran within 4hours in 89% of 123 enrolees according to an ongoing trial of patients with uncontrolled bleeding or who require urgent procedures.…”