Objective: Intravenous thrombolysis (IVT) is contraindicated in case of anticoagulation. Idarucizumab, an antibody specifically binding the direct thrombin inhibitor dabigatran, has been available from October 2015 to promptly reverse anticoagulation. Thereafter, anecdotal cases of IVT after dabigatran reversal with idarucizumab have been reported. Here we describe two cases, and provide a systematic review of all reported cases, defining effectiveness and safety of this treatment paradigm. Methods: Two patients eligible for IVT for stroke while taking dabigatran were identified from our stroke registry. A systematic review was performed according to PRISMA guidelines and specified criteria (PROSPERO-CRD42017060274). Multivariate analysis was performed to define factors influencing follow-up modified Rankin Scale (mRS). Results: Including ours, we collected 55 cases, mean age 74.3 years, 43.6% female. At admission, Median NIHSS was 10 (interquartile range -IQR- 6-14) and mean time from last dabigatran intake was 344 minutes. Clotting studies were abnormal in up to 96% of cases, with prompt normalization after idarucizumab administration. IVT benefitted 45 patients (81.9%) (mean time to rtPA 175 minutes), with 5 points median NIHSS improvement (IQR 3-10). Three patients developed symptomatic hemorrhagic transformation, 4 died. An mRS<2 was achieved at follow-up in 56.8% of patients, but mRS did not depend on time to IVT or last dabigatran assumption. Conclusions: Experience with IVT after dabigatran reversal with idarucizumab is limited. However, the treatment paradigm seems safe, and reaches a benefit in the majority of patients receiving it. Larger cohorts are needed to clearly assess bleeding complications and the risk of thrombosis.
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