Normandie Université, UNICAEN, Unité Neurovasculaire, CHU Caen, Caen, France.
Service d'Hématologie-Hémostase, Centre Régional de Traitement de l'Hémophilie, UMR CNRS 7292, Hôpital Trousseau, CHRU de Tours et Université François Rabelais, Tours, France.
Eur J Neurol. 2018 May;25(5):747-e52. doi: 10.1111/ene.13582. Epub 2018 Mar 9.
Whereas intravenous thrombolysis (IVT) is allowed for acute ischaemic stroke in patients on vitamin K antagonists with international normalized ratio ≤1.7, there are no similar recommendations for patients on direct oral anticoagulants (DOACs), notably due to the lack of coagulation tests to assess the therapeutic effects. Although the literature is scarce, consisting of small case series and retrospective studies, considering the frequency of this situation the French Vascular Neurology Society and the French Study Group on Haemostasis and Thrombosis have worked on a joint position paper to provide a practical position regarding the emergency management of ischaemic stroke in patients on DOACs.
Based on a review of the literature, the authors wrote a first text that was submitted to a broad panel of members from the two societies. The text was then amended by the authors to address experts' comments and to reach a consensus.
In patients with normal renal function and who stopped the DOAC for at least 48 h, the management should not differ from that in patients without oral anticoagulant. In patients who are still on DOACs, mechanical thrombectomy is encouraged preferentially when applicable in first line. Otherwise, when specific tests are available, values <50 ng/ml indicate that IVT is allowed. In the absence of specific tests, standard tests (thrombin time, prothrombin time and activated partial thromboplastin time) can be used for dabigatran and rivaroxaban, although interpretation of these tests may be less reliable. In some patients on dabigatran, idarucizumab may be used before IVT.
In this expert opinion paper, it is suggested that IVT can be performed in patients selected according to the time elapsed since the drug was last taken, renal function, type of hospital where the patient is admitted and plasma concentration of DOAC.
对于国际标准化比值（INR）≤1.7 的维生素 K 拮抗剂（VKA）急性缺血性脑卒中患者，可进行静脉溶栓（IVT）治疗，而对于直接口服抗凝剂（DOAC）患者则无类似建议，这主要是因为缺乏评估治疗效果的凝血检测。尽管文献很少，仅包含一些小病例系列和回顾性研究，但考虑到这种情况的频率，法国血管神经病学学会和法国止血与血栓形成研究组共同撰写了一份立场文件，以提供 DOAC 患者缺血性脑卒中急救管理的实用建议。
基于文献复习，作者撰写了一份初稿，并提交给来自两个学会的广泛成员小组。随后，作者对文本进行了修订，以解决专家的意见并达成共识。
对于肾功能正常且至少停药 48 小时的患者，其管理不应与未服用抗凝剂的患者不同。对于仍在服用 DOAC 的患者，在适用的情况下，优先鼓励机械取栓作为一线治疗。否则，在有特定检测手段的情况下，<50ng/ml 的检测值提示可进行 IVT。在没有特定检测手段的情况下，标准检测（凝血酶时间、凝血酶原时间和活化部分凝血活酶时间）可用于达比加群和利伐沙班，但这些检测的解释可能不太可靠。对于一些服用达比加群的患者，在进行 IVT 之前可能会使用依达鲁单抗。
在这份专家意见文件中，建议根据患者最后一次服药时间、肾功能、患者入院医院类型和 DOAC 血浆浓度等因素选择患者进行 IVT。
