Idarucizumab in acute ischemic stroke patients treated with thrombolysis: single center experience.

Background: Patients with acute ischemic stroke anticoagulated with dabigatran may be candidates for intravenous thrombolysis (IV-tPA) after idarucizumab administration followed by normalization of coagulation parameters. We report the case series of acute ischemic stroke patients focusing on laboratory findings.      
Methods: We identified consecutive idarucizumab-treated patients with acute ischemic stroke and atrial fibrillation. Neurologic deficit was measured by the National Institutes of Health Stroke Scale (NIHSS) and 90-day modified Rankin Scale (mRS). The anticoagulant effect of dabigatran and its reversal by idarucizumab was assessed by measuring activated partial thromboplastin time (aPTT), thrombin time (TT) and diluted thrombin time (dTT). The safety outcome was symptomatic intracranial hemorrhage (sICH) defined according to ECASS III study.          
Results: We enrolled 5 IV-tPA-treated patients (40% female, mean age 70±9.7 years, admission median NIHSS 7, IQR 7) after administration of 5g idarucizumab. Treatment with 150mg dabigatran was confirmed in 2 patients (40%). After idarucizumab, laboratory tests in 3 patients (60%) resulted in the immediate reversal of dabigatran anticoagulant activity and 2 patients (40%) had prolonged TT (26s and 25s). In all cases IV-tPA continued. Post-treatment CT in patients with prolonged TT did not reveal any intracranial hemorrhage. 3 patients (60%) had 90-day mRS 0-2, neurologic improvement of ≥ 4 in NIHSS score at discharge was confirmed in 3 patients (60%). 
Conclusion: Our small single center experience supports the eligibility of IV-tPA after idarucizumab even in patients with persistent slight elevation of TT. Safe upper limit of TT has to be determined in larger series.

IDARUCIZUMAB IN ACUTE ISCHEMIC STROKE PATIENTS TREATED WITH THROMBOLYSIS: SINGLE CENTER EXPERIENCE