| Abstract [eng] |
Although intravenous thrombolysis (IVT) is an effective treatment for acute ischemic stroke, it is available only to a limited number of patients. One reason for this is the strict contraindication criteria. With the increasing prevalence of atrial fibrillation and, consequently, the growing use of anticoagulants, this is particularly relevant because thrombolytic treatment is contraindicated if direct oral anticoagulants (DOACs) have been taken within the last 48 hours before the onset of stroke symptoms. Recently, several studies have been published comparing the safety and efficacy of IVT in patients who have taken DOACs. Aim of the study: To assess, based on clinical cases and available literature, whether the use of IVT in patients with acute ischemic stroke who have taken DOACs is an acceptable treatment option. Objectives: 1. To describe the clinical cases of patients treated with IVT for acute ischemic stroke at the Republican Vilnius university hospital (RVUL) who had taken DOACs within the previous 48 hours, as well as the safety and effectiveness of such treatment; 2. To conduct a literature review on the safety and efficacy of IVT in patients with acute ischemic stroke who had taken DOACs; 3. To discuss different patient selection strategies for treatment: reversal of the anticoagulant effect and assessment of laboratory parameters; 4. To formulate conclusions and recommendations for clinical practice based on the collected information. Methods: The PubMed database was used to select articles suitable for the literature review. The search keywords were: ( (stroke OR acute ischemic stroke) AND (alteplase OR fibrinolysis OR intravenous thrombolysis OR thrombolytic therapy OR tenecteplase) AND (direct acting oral anticoagulants OR DOAC OR NOAC OR dabigatran OR rivaroxaban OR apixaban OR edoxaban) ). Results: In studies that examined reversal of the dabigatran effect with idarucizumab or laboratory assessment of DOAC activity, IVT was safely administered to a larger number of patients. It is likely that IVT may be used even more frequently in the future, as emerging data suggests that IVT remains a safe treatment option even when DOAC concentrations exceed 100 ng/ml. In studies comparing patients who had taken DOACs before IVT with patients who had not taken DOACs before IVT, no significant difference in safety was found. Some studies indicate that IVT outcomes were better in patients who had taken DOACs before IVT. Conclusions: 1. The outcomes of patients treated with IVT for acute ischemic stroke at RVUL who had taken DOACs within the previous 48 hours varied. 2. No difference in the safety and efficacy of IVT was found between patients who had taken DOACs and those who had not used anticoagulants before IVT; however, good functional outcomes were achieved more often than in patients who did not receive IVT after anticoagulant use. 3. Reversal of the dabigatran effect with idarucizumab or laboratory assessment of DOAC concentration allows IVT to be administered to a larger number of patients without compromising treatment safety. 4. At present, no high-quality clinical trials have been conducted that would justify changing the current guidelines; however, an individualized treatment decision may be considered, taking into account stroke severity and individual patient characteristics, and following discussion of the potential benefits and risks of treatment with the patient and their family members. |
