Background
Acute ischemic stroke thrombolysis in patients taking dabigatran is controversial
because of a presumed increased risk of symptomatic hemorrhagic transformation. Using
data from our local hematopathology laboratory, we developed a thrombolysis protocol
for acute ischemic stroke patients taking dabigatran.
Methods
A local thrombin time (TT)–dabigatran concentration relationship was calculated using
dabigatran calibrators. The effect of dabigatran on activated partial thromboplastin
time (aPTT) and prothrombin time (PT) (international normalized ratio [INR]) was also
measured. A protocol was developed, in which a dabigatran concentration less than
10 ng/mL (corresponding to a TT < 38 seconds or a normal aPTT) was selected as the
upper limit for thrombolysis. Consecutive patients presenting with acute stroke were
then enrolled in this prospective study.
Results
In the 8 months after development of the protocol, 13 potential thrombolysis candidates
taking dabigatran were assessed at a median (interquartile range) time of 192 (143)
minutes. The median National Institutes of Health Stroke Scale score was 18 (20).
The mean time from arrival to TT, aPTT, and PT (INR) results were 39 ± 4.1 minutes,
21 ± 6.5 minutes, and 21 ± 6.5 minutes, respectively. Based on TT/aPTT, 4 patients
were ineligible for thrombolysis. Six patients were not treated because of minor or
resolving symptoms and another presented with intracerebral hemorrhage. Two patients
were treated with intravenous tissue plasminogen activator (tPA), without symptomatic
hemorrhagic transformation in either case. In 3 patients (42.8%), aPTT was normal,
despite a prolonged TT.
Conclusions
Administration of intravenous tPA in dabigatran-treated patients is feasible. Although,
the relationship between dabigatran concentrations and coagulation measures varies
between laboratories, individual protocols, preferably based on TT, can be developed
at acute stroke treatment centers.
Key Words
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Article info
Publication history
Published online: January 09, 2014
Accepted:
November 13,
2013
Received in revised form:
November 7,
2013
Received:
July 23,
2013
Footnotes
Disclosure: None.
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.11.013
Copyright
© 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.
