Purpose: Here reports an immediate reversal of dabigatran with idarucizumab, a humanized monoclonal antibody fragment for dabigatran, for the purpose of subsequent intravenous thrombolysis for acute ischemic stroke led to patient safety and successful recanalization. Case: Fifty minutes has passed since 77 year-old female with hypertension and transient atrial fibrillation suddenly fell down on the shopping center. On an immediate transfer to our stroke center, she demonstrated disturbed consciousness, slurred speech, left hemiparesis and unilateral spatial neglect, whose NIHSS scores reached to 12. No early ischemic CT signs provided us clinical diagnosis of cardiogenic embolism in the right frontal lobe, with no other contraindication than her prolonged APTT to 44 seconds and dabigatran 110mg intake 3 hours before. The neutralization of dabigatran by a 10-min intravenous injecton of 5g idarucizumab made her APTT returned to 27 sec immediately, when recombinant tissue-type plasminogen activator alteplase was started 90 minutes after ictus. A 60-min duration of alteplase infusion mitigated her neurological deficits completely and MRI demonstrated patchy cortical infarcts on the right frontal lobe and patent intracranial vessels (TICI 3). Symptomatic or asymptomatic intracranial hemorrhage was not observed at all. Comments: The latest officially-authorized Japanese clinical guides 2018 recommend that thrombolysis can be approved both if the time of the late dose of direct oral anticoagulants exceeds 4 hours and if commonly available anticoagulation markers are normal or subnormal. Even for dabigatran users, if patients does not meet the above criteria, direct mechanical thrombectomy can be considered without idarucizumab or rt-PA, however, an alternative option of rapid antagonizaiton with idarucizumab enough to reverse the anticoagulant activity of dabigatoran can be applied to the patients who regain eligibility for intravenous thrombolysis, while thrombectomy cannot be promptly performed.
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