scholarly journals Author Reply to “Intravenous thrombolysis in patients taking direct oral anticoagulants (European stroke organisation intravenous thrombolysis guidelines comment)

2021 ◽  
pp. 239698732110585
Author(s):  
Gian Marco De Marchis ◽  
Guillaume Turc ◽  
William Whiteley ◽  
Georgios Tsivgoulis
Keyword(s):  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Intravenous Thrombolysis ◽  
Author Reply

Abstract 4: Safety of Intravenous Thrombolysis Among Patients Taking Direct Oral Anticoagulants: A Systematic Review and Meta-analysis

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Shima Shahjouei ◽  
Georgios Tsivgoulis ◽  
Nitin Goyal ◽  
Andrei V. Alexandrov ◽  
Ramin Zand
Keyword(s):  
Systematic Review ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Intravenous Thrombolysis

scholarly journals Recanalisation therapies for acute ischaemic stroke in patients on direct oral anticoagulants

2021 ◽  
Vol 92 (5) ◽  
pp. 534-541
Author(s):  
David J Seiffge ◽  
Thomas Meinel ◽  
Jan Christoph Purrucker ◽  
Johannes Kaesmacher ◽  
Urs Fischer ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Mechanical Thrombectomy ◽  
Current Knowledge ◽  
Anticoagulant Activity ◽  
Therapeutic Option ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Intravenous Thrombolysis ◽  
Vessel Occlusion ◽  
Reversal Agents

Direct oral anticoagulants (DOACs) have emerged as primary therapeutic option for stroke prevention in patients with atrial fibrillation. However, patients may have ischaemic stroke despite DOAC therapy and there is uncertainty whether those patients can safely receive intravenous thrombolysis or mechanical thrombectomy. In this review, we summarise and discuss current knowledge about different approaches to select patient. Time since last DOAC intake—as a surrogate for anticoagulant activity—is easy to use but limited by interindividual variability of drug pharmacokinetics and long cut-offs (>48 hours). Measuring anticoagulant activity using drug-specific coagulation assays showed promising safety results. Large proportion of patients at low anticoagulant activity seem to be potentially treatable but there remains uncertainty about exact safe cut-off values and limited assay availability. The use of specific reversal agents (ie, idarucizumab or andexanet alfa) prior to thrombolysis is a new emerging option with first data reporting safety but issues including health economics need to be elucidated. Mechanical thrombectomy appears to be safe without any specific selection criteria applied. In patients on DOAC therapy with large vessel occlusion, decision for intravenous thrombolysis should not delay thrombectomy (eg, direct thrombectomy or immediate transfer to a thrombectomy-capable centre recommended). Precision medicine using a tailored approach combining clinicoradiological information (ie, penumbra and vessel status), anticoagulant activity and use of specific reversal agents only if necessary seems a reasonable choice.

scholarly journals Acute Stroke Treatment in an Anticoagulated Patient: When Is Thrombolysis an Option?

2021 ◽  
Vol 23 (12) ◽  
Author(s):  
Teresa Siller ◽  
Arvind Chandratheva ◽  
Philipp Bücke ◽  
David J. Werring ◽  
David Seiffge
Keyword(s):  
Selection Process ◽  
Anticoagulant Activity ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Intravenous Thrombolysis ◽  
Current Evidence ◽  
Thrombin Inhibitor ◽  
Reversal Agent ◽  
Stroke Treatment ◽  
Safety Issues

Abstract Purpose of Review Direct oral anticoagulants (DOACs: the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban and the direct thrombin inhibitor dabigatran) are the mainstay of stroke prevention in patients with non-valvular atrial fibrillation (AF). Nevertheless, there is a residual stroke risk of 1–2% per year despite DOAC therapy. Intravenous thrombolysis (IVT) reduces morbidity in patients with ischemic stroke and improves functional outcome. Prior DOAC therapy is a (relative) contraindication for IVT but emerging evidence supports its use in selected patients. Recent Findings Recent observational studies highlighted that IVT in patients on prior DOAC therapy seems feasible and did not yield major safety issues. Different selection criteria and approaches have been studied including selection by DOAC plasma levels, non-specific coagulation assays, time since last intake, and prior reversal agent use. The optimal selection process is however not clear and most studies comprised few patients. Summary IVT in patients taking DOAC is a clinically challenging scenario. Several approaches have been proposed without major safety issues but current evidence is weak. A patient-oriented approach balancing potential benefits of IVT (i.e., amount of salvageable penumbra) against expected bleeding risk including appropriate monitoring of anticoagulant activity seem justified.

scholarly journals Safety of Intravenous Thrombolysis Among Patients Taking Direct Oral Anticoagulants

Stroke ◽  
2020 ◽  
Vol 51 (2) ◽  
pp. 533-541 ◽  
Author(s):  
Shima Shahjouei ◽  
Georgios Tsivgoulis ◽  
Nitin Goyal ◽  
Alireza Sadighi ◽  
Ashkan Mowla ◽  
...  
Keyword(s):  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Intravenous Thrombolysis

scholarly journals Cervical and intracranial artery dissections

2021 ◽  
Vol 14 ◽  
pp. 175628642110372
Author(s):  
Stefan T. Engelter ◽  
Philippe Lyrer ◽  
Christopher Traenka
Keyword(s):  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Intravenous Thrombolysis ◽  
Future Research ◽  
Artery Dissection ◽  
Intracranial Artery ◽  
Antithrombotic Agent ◽  
Vessel Occlusion ◽  
Randomized Controlled

This review summarizes recent therapeutic advances in cervical (CeAD) and intracranial artery dissection (IAD) research. Despite unproven benefits, but in the absence of any signal of harm, in patients, with acute ischemic stroke attributable to CeAD, intravenous thrombolysis and, in case of large-vessel occlusion, endovascular revascularization should be considered. Future research will clarify which patients benefit most from either treatment modality. For stroke prevention, the recently published randomized controlled TREAT-CAD study showed that, against the initial hypothesis, aspirin was not shown non-inferior to anticoagulation with vitamin K antagonists (VKAs). With the results of two randomized controlled trials (CADISS and TREAT-CAD) available now, the evidence to consider aspirin as the standard therapy of CeAD is weak. Further analyses might clarify whether the assumption supports, in particular, that patients presenting with cerebral ischemia, clinical or subclinical with magnetic resonance imaging surrogates, might benefit most from VKA treatment. In turn, it remains to be shown, whether in CeAD patients presenting with pure local symptoms and without hemodynamic compromise, antiplatelets are sufficient, and whether a dual antiplatelet therapy during the first weeks of treatment is recommendable. The observation that ischemic strokes occurred (or recurred) very early after CeAD diagnosis, consistently across randomized and observational studies, supports the recommendation to start antithrombotic treatment immediately, whatever antithrombotic agent is chosen in each individual case. The lack of a license for the use in CeAD patients and the paucity of data are still arguments against the use of direct oral anticoagulants in CeAD. Nevertheless, due to their beneficial safety and efficacy profile proven in atrial fibrillation, these agents are a worthwhile treatment option to be tested in further CeAD treatment trials. In IAD, the experience with the use of antithrombotic agents is limited. As the risk of suffering intracranial hemorrhage is higher in IAD than in CeAD, the use of antithrombotic therapy in IAD remains controversial.

Intravenous thrombolysis for acute ischaemic stroke in patients on direct oral anticoagulants

2018 ◽  
Vol 25 (5) ◽  
pp. 747-e52 ◽  
Author(s):  
E. Touzé ◽  
Y. Gruel ◽  
I. Gouin-Thibault ◽  
E. De Maistre ◽  
S. Susen ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Intravenous Thrombolysis
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