With the approval of idarucizumab, a novel monoclonal antibody fragment with a high potency to reverse the anticoagulant effects of dabigatran within minutes, the question arose if recombinant tissue plasminogen activator (rt-PA) could be used after reversal of dabigatran with idarucizumab in individuals with newly occurring ischemic stroke. However, one major concern was the lack of specific antidotes. Substantially decreased rates of bleeding complications in comparison with warfarin, especially when considering intracerebral hemorrhage, are an advantage of NOAC therapy. Besides dabigatran, three additional non-vitamin-K-dependent oral anticoagulants (NOACs) are currently available. Neurologists have used dabigatran mostly for secondary prevention of cardioembolic stroke in patients with atrial fibrillation since the phase III RE-LY trial showed positive results for the prevention of stroke or systemic embolism as compared with warfarin. Thus, idarucizumab represents a new therapeutic option for patients receiving dabigatran treatment, reestablishing their eligibility for recombinant tissue plasminogen activator thrombolysis.
ConclusionsĪpplying a recombinant tissue plasminogen activator after antagonizing dabigatran with idarucizumab is feasible and easy to manage in an emergency room or stroke unit. After providing written consent, he received two doses of 2.5 g of idarucizumab over 20 minutes followed by standard protocol in-label recombinant tissue plasminogen activator application. Case presentationĪ 75-year-old Caucasian man presented to our hospital with severe aphasia and mild hemiparesis. We report what we believe to be the first case of ischemic stroke successfully treated with recombinant tissue plasminogen activator after antagonizing dabigatran with the monoclonal antibody idarucizumab, recently approved worldwide. Effective anticoagulation routinely precludes patients from receiving intravenous thrombolysis with recombinant tissue plasminogen activator to reverse severe symptoms of ischemic stroke.
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