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FIRST CASE IN ISRAEL OF INTRAVENOUS THROMBOLYSIS WITH TISSUE PLASMINOGEN ACTIVATOR (TPA) IN ACUTE ISCHEMIC STROKE AFTER DABIGATRAN REVERSAL WITH IDARUCIZUMAB

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ESOC-2019

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Abstract

Background: Dabigatran is an oral anticoagulant used for stroke prevention in nonvalvular atrial fibrillation. Further indications include treatment and prevention of deep vein thrombosis (DVT) and pulmonary embolism. FDA recently approved the use of dabigatran antidote (idarucizumab). Methods: We report here the first case in Israel treated with tPA after dabigatran reversal with idarucizumab, Results: A 82-year-old woman who presented an acute ischemic stroke (NIHSS 9) in the anterior circulation with right leg hemiplegia and aphasia was admitted to ED. Past medical history revealed hypertension, hyperlipidemia, hypothyroidism and ischemic heart disease. She was treated with dabigatran for DVT. Brain CT scan demonstrated an old ischemic stroke in the right frontal lobe and left cerebellum with no evidence of acute ischemic stroke. Coagulation parameters were abnormal. Before performing thrombolysis, we neutralized the anticoagulant activity of dabigatran with idarucizumab. A significant improvement in leg weakness was observed and her speech became more fluent. Unfortunately, 4 to 5 hours after treatment we noticed a deterioration in her consciousness. She became drowsy and right hemiplegic with global aphasia. EEG showed slow mild to moderate bi-frontal activity. A lumbar puncture revealed no evidence of CNS infection. Brain MRI demonstrated an acute right MCA infarct and another acute left ACA territory on DWI. Conclusion: Idarucizumab might predisposed the patient to a hyper-coagulative state that dabigatran would have prevented. This may explain the second stroke in a different territory few hours later. We cannot completely exclude a prothrombotic effect of idarucizumab in our patient or a negative impact of idarucizumab on tPA effectiveness.

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© Copyright 2020 Morressier GmbH.
All rights reserved.