Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Sep 16:17:17562864241276206.
doi: 10.1177/17562864241276206. eCollection 2024.

Hemorrhagic complications after stroke treatment with intravenous thrombolysis despite use of direct oral anticoagulants: an observational study

Antonia Kleeberg  1 , Peter A Ringleb  1 , Ioana Huber  1 , Jessica Jesser  2 , Markus Möhlenbruch  2 , Jan C Purrucker  3
Affiliations

Hemorrhagic complications after stroke treatment with intravenous thrombolysis despite use of direct oral anticoagulants: an observational study

Antonia Kleeberg et al. Ther Adv Neurol Disord. .

Abstract

Background: For patients experiencing ischemic stroke despite receiving therapy with direct oral anticoagulants (DOAC) and without endovascular treatment options, therapeutic prospects are currently dismal. Current guidelines recommend intravenous thrombolysis (IVT) only for patients who have received DOAC in very restricted settings, as an increased risk of bleeding is suspected. However, recent retrospective observational studies suggest that IVT is safe despite DOAC pretreatment.

Objectives: To provide further evidence that IVT despite previous DOAC treatment is not associated with an increased risk of bleeding.

Design: Observational retrospective study.

Methods: Demographic, clinical, and radiological data of patients who received IVT (+/- endovascular thrombectomy) despite DOAC pretreatment between June 2021 and January 2024 were analyzed using descriptive statistics, including DOAC plasma concentration at admission. Secondary intracranial hemorrhages and functional outcomes at 3 months were assessed. Since 2023, patients have been treated according to a modified local standard operating procedure at our hospital, allowing for IVT despite DOAC pretreatment regardless of DOAC plasma levels or the use of reversal agents.

Results: Of 1821 patients treated with acute recanalization procedures during the study period, N = 35 had received IVT with (18) or without (17) additional endovascular therapy. Among these patients with a wide age range (42-97 years) and DOAC plasma concentrations up to 369 ng/ml, only one developed symptomatic intracranial hemorrhage. A favorable outcome (modified Rankin scale score 0-2) after 3 months was observed in 57% (20) of the patients.

Conclusion: IVT despite direct oral anticoagulation seems to be safe, even at advanced age and high DOAC plasma levels.

Keywords: ischemic stroke; oral anticoagulation; thrombolysis.

Plain language summary

Bleeding problems after stroke treatment with clot-busting drugs, even when taking blood thinners After local treatment rules were changed to allow clot-busting treatment for stroke even if patients had recently used blood thinners, the number of patients receiving this treatment more than tripled. Despite not checking blood test results before treatment, serious brain bleeding was not common. The levels of blood thinners in the patients’ blood did not affect the chances of having any kind of brain bleeding. This new information supports the growing evidence that clot-busting treatment may be safe for patients taking novel blood thinners.

PubMed Disclaimer

Figures

Figure 1.
Figure 1.
Flow diagram of patient screening process.
See this image and copyright information in PMC

References

    1. Kam W, Holmes DN, Hernandez AF, et al.. Association of recent use of non-Vitamin K antagonist oral anticoagulants with intracranial hemorrhage among patients with acute ischemic stroke treated with alteplase. JAMA 2022; 327: 760–771. - PMC - PubMed
    1. Meinel TR, Wilson D, Gensicke H, et al.. Intravenous thrombolysis in patients with ischemic stroke and recent ingestion of direct oral anticoagulants. JAMA Neurol 2023; 80: 233–243. - PMC - PubMed
    1. Tsai TY, Liu YC, Huang WT, et al.. Risk of bleeding following non-Vitamin K antagonist oral anticoagulant use in patients with acute ischemic stroke treated with alteplase. JAMA Intern Med 2024; 184: 37–45. - PMC - PubMed
    1. Bücke P, Jung S, Kaesmacher J, et al.. Intravenous thrombolysis in patients with recent intake of direct oral anticoagulants: a target trial analysis after the liberalization of institutional guidelines. Eur Stroke J 2024: 23969873241252751. - PMC - PubMed
    1. Behnoush AH, Khalaji A, Bahiraie P, et al.. Meta-analysis of outcomes following intravenous thrombolysis in patients with ischemic stroke on direct oral anticoagulants. BMC Neurol 2023; 23: 440. - PMC - PubMed

LinkOut - more resources