Stroke Note Published online: September 28, 2010
Cerebrovasc Dis 2010;30:533–534 DOI: 10.1159/000319886
Intravenous Thrombolysis with Recombinant Tissue Plasminogen Activator in a Stroke Patient Treated with Dabigatran Ann De Smedt a , Sylvie De Raedt a , Koenraad Nieboer b, Jacques De Keyser a , Raf Brouns a Departments of aNeurology and bRadiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
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Intravenous administration of recombinant tissue plasminogen activator (rtPA) is the only approved therapy for acute ischemic stroke [1]. Because of a supposed higher risk of hemorrhage, especially in the brain, concomitant use of anticoagulants is a contraindication for this treatment. Dabigatran is an oral anticoagulant of the class of direct thrombin inhibitors and seems to be on the verge of entering rou-
tine clinical practice as a replacement of warfarin [2]. Data on the bleeding risk in patients treated with rtPA while taking dabigatran are nonexistent. We report on a 46-year-old right-handed woman presenting with abrupt onset of left hemiplegia and hemihypesthesia. NIHSS (The National Institutes of Health Stroke Scale) score was 19. Conventional noncontrast computed tomography (CT) of the brain showed no abnormality. Perfusion CT revealed an extensive region of decreased perfusion, mainly consisting of ischemic penumbra in the territory of the right middle cerebral artery (fig. 1a). A dissection of the right common and internal carotid artery was diagnosed by CT angiography and carotid duplex ultrasound (fig. 1b). The patient was known with paroxysmal atrial fibrillation and participated in the RELY-ABLE trial, which is an extension study on the use of dabigatran in patients who completed the RE-LY trial [3]. Data on the allocation of this patient to the treatment arm taking dabigatran 110 mg twice daily or 150 mg twice daily are not available. After consulting with Boehringer Ingelheim and informed consent, we started intravenous rtPA therapy just below 4.5 h after onset of symptoms and 7 h after last intake of dabigatran. The platelet count before initiation of the throm-
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b
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Fig. 1. Perfusion CT of the brain and CT angiography of the cervical arteries demonstrating hypoperfusion in the territory of the right middle cerebral artery (a) and dissection of the right common carotid artery (arrow; b).
Disclosure Statement The authors state that there are no conflicts of interest.
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References 1 Adams HP Jr, del Zoppo G, Alberts MJ, et al: Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007;38:1655–1711. 2 Marti-Fabregas J, Mateo J: Old and new anticoagulant agents for the prevention and treatment of patients with ischemic stroke. Cerebrovasc Dis 2009;27(suppl 1):111–119. 3 Connolly SJ, Ezekowitz MD, Yusuf S, et al: Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361:1139–1151. Dr. R. Brouns Department of Neurology, Universitair Ziekenhuis Brussel Laarbeeklaan 101 BE–1090 Brussels (Belgium) Tel. +32 2 477 60 12, Fax +32 2 477 68 00 E-Mail Raf.Brouns @ uzbrussel.be
Stroke Note
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bolytic therapy was 347 ! 109/l (normal: 158–450 ! 109/l), the prothrombin time was 87% (normal: 170%), the international normalized ratio was 1.2 (normal: 0.8–1.3), the activated partial thromboplastin time was 34.8 s (normal: 22.2–34.4 s) and the fibrinogen level was 506 mg/dl (normal: 180–400 mg/dl). There were no complications. Reevaluation at 24 h after symptom onset showed improvement in the neurological deficit with an NIHSS score of 12. The platelet count was 325 ! 109/l, the prothrombin time was 75%, the international normalized ratio was 1.3, the activated partial thromboplastin time was 29.0 s and the fibrinogen level was 531 mg/dl. A control CT scan of the brain showed an infarction confined to the right putamen, without signs of intracranial hemorrhage. At the patient’s request, participation in the RELY-ABLE trial was discontinued and secondary prevention with coumarin initiated. Our case justifies further studies on the safety of rtPA therapy in acute ischemic stroke patients using dabigatran.
