Amin Sheyar, Kasischke Karl A, Elsayed Kareem, Burgin W Scott, Rose David Z
Neurology, University of South Florida Morsani College of Medicine, Tampa, USA.
Cureus. 2022 Jan 19;14(1):e21406. doi: 10.7759/cureus.21406. eCollection 2022 Jan.
Direct oral anticoagulant (DOAC) reversal before intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients is well-documented in Europe, specifically for dabigatran: the selective humanized monoclonal antibody fragment idarucizumab, given to neutralize dabigatran prior to IVT, was associated with improved outcomes post-IVT. However, in the United States, this approach is rarely reported and not endorsed by guidelines. Therefore, further reporting on this is needed and neuroradiographic correlation may help validate this concept. At our hospital in Tampa, Florida, two octogenarians with atrial fibrillation, adherent with the DOAC dabigatran, presented with AIS shortly after symptom onset. Both received idarucizumab, then IVT. Clinical outcomes, treatment times, and perfusion-based neuroradiographic parameters were assessed. Patient A had a 41 ml penumbra on computed tomography perfusion (CTP) scan that decreased to 15 ml in final infarct volume on follow-up imaging, resulting in a 26 ml penumbral salvage (63.4%), and National Institutes of Health Stroke Scale (NIHSS) improved from 11 to 9 . Patient B had a 23 ml penumbra on CTP that decreased to 0.5 ml on follow-up imaging, resulting in a 22.5 ml penumbral salvage (97.8%), and NIHSS improved from 9 to 4. Neither developed bleeding complications. Both had delayed door-to-needle times but nevertheless demonstrated clinical neurological improvements. In our limited experience, IVT after immediate DOAC reversal in AIS patients on dabigatran was associated with clinical improvement in NIHSS by 2 to 5 points (with no neuroworsening), and penumbral salvage of ischemic brain tissue on neuroimaging ranging from 63.4% to 97.8%. Further reporting on this may lead to greater IVT use and better outcomes in "DOAC failures", especially for patients without other acute treatment options such as mechanical thrombectomy. Research into other anticoagulant reversal agents pre-IVT in AIS is also warranted.
在欧洲，急性缺血性卒中（AIS）患者在静脉溶栓（IVT）前进行直接口服抗凝剂（DOAC）逆转已有充分记录，特别是对于达比加群：在IVT前使用选择性人源化单克隆抗体片段依达赛珠单抗来中和达比加群，与IVT后改善的预后相关。然而，在美国，这种方法很少被报道，也未得到指南认可。因此，需要进一步报告此事，且神经影像学相关性可能有助于验证这一概念。在佛罗里达州坦帕市的我们医院，两名患有心房颤动且坚持服用DOAC达比加群的八旬老人，在症状发作后不久出现了AIS。两人均接受了依达赛珠单抗治疗，然后进行了IVT。评估了临床结局、治疗时间和基于灌注的神经影像学参数。患者A在计算机断层扫描灌注（CTP）扫描中有41毫升的半暗带，随访成像时最终梗死体积降至15毫升，半暗带挽救了26毫升（63.4%），美国国立卫生研究院卒中量表（NIHSS）评分从11分改善至9分。患者B在CTP上有23毫升的半暗带，随访成像时降至0.5毫升，半暗带挽救了22.5毫升（97.8%），NIHSS评分从9分改善至4分。两人均未出现出血并发症。两人的门到针时间均延迟，但仍表现出临床神经功能改善。根据我们有限的经验，在服用达比加群的AIS患者中，立即进行DOAC逆转后进行IVT与NIHSS评分临床改善2至5分（无神经功能恶化）相关，神经影像学显示缺血脑组织的半暗带挽救率在63.4%至97.8%之间。对此进行进一步报告可能会导致在“DOAC失效”患者中更多地使用IVT并获得更好的结局，特别是对于没有其他急性治疗选择（如机械取栓）的患者。对AIS患者IVT前其他抗凝逆转剂的研究也很有必要。
