title: Intravenous thrombolysis in a stroke patient taking dabigatran.
abstract: We describe the use of intravenous thrombolysis with recombinant tissue plasminogen activator (IV-rtPA) in a patient with concomitant dabigatran use. A 64-year-old man with a history of coronary artery disease, pacemaker placement, and atrial fibrillation developed acute right arm/face weakness and dysarthria. He was unable to list his home medications. His platelet count was 167 × 10(9)/L (normal 150-399 × 10(9)/L), and his activated partial thromboplastin time (aPTT) was 37.6 seconds (normal 24.0-33.0 seconds). His international normalized ratio (INR) was 1.1. He received IV-rtPA at 3 hours and 25 minutes after the onset of symptoms. After IV-rtPA was administered, it was discovered that the patient had been taking dabigatran for 2 months. After IV-rtPA, the patient developed severe superficial left arm ecchymoses but remained without cerebral complications. On poststroke day 1, his fibrinogen level was low at 63 mg % (normal 190-395 mg %), his aPTT was normal at 33, and his INR was elevated at 1.72 but decreased to 1.18 on the following day. Repeat computed tomographic imaging of his brain confirmed a left middle cerebral artery ischemic cortical infarct. We report a case of an acute stroke patient taking dabigatran who received IV-rtPA. In the acute stroke setting, clinicians should be aware of the increasing use of dabigatran in patients with atrial fibrillation when considering IV-rtPA. Although aPTT does not provide a linear response to dabigatran therapy, the presence of a completely normal PTT may exclude therapeutic dabigatran anticoagulation.
authors.affiliation: Section of Stroke and Neurocritical Care, Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois 60612, USA. vivien_lee@rush.edu
authors.forename: Vivien H
authors.initials: VH
authors.lastname: Lee
authors.forename: James J
authors.initials: JJ
authors.lastname: Conners
authors.forename: Shyam
authors.initials: S
authors.lastname: Prabhakaran
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000097:blood / Q000150:complications / Q000188:drug therapy*; D001562:Benzimidazoles / Q000627:therapeutic use*; D001777:Blood Coagulation / Q000187:drug effects; D002533:Cerebral Angiography / Q000379:methods; D000069604:Dabigatran; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D010314:Partial Thromboplastin Time; D010976:Platelet Count; D015912:Thrombolytic Therapy; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D015091:beta-Alanine / Q000031:analogs & derivatives* / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D001562:Benzimidazoles; D005343:Fibrinolytic Agents; D015091:beta-Alanine; D010959:Tissue Plasminogen Activator; D000069604:Dabigatran