title: Treatment of acute ischaemic stroke with thrombolysis or thrombectomy in patients receiving anti-thrombotic treatment.
abstract: Systemic thrombolysis with alteplase is the only approved medical treatment for patients with acute ischaemic stroke. Thrombectomy is also increasingly used to treat proximal occlusions of the cerebral arteries, but has not shown superiority over systemic thrombolysis with alteplase. Many patients with acute ischaemic stroke are pretreated with antiplatelet or anticoagulant drugs, which can increase the bleeding risk of thrombolysis or thrombectomy. Pretreatment with aspirin monotherapy increases the bleeding risk of alteplase in both observational and randomised trials with no effect on clinical outcome, and the risk of intracerebral haemorrhage is increased with the combination of aspirin and clopidogrel. Antiplatelet drugs should not be given in the first 24 h after alteplase treatment. Data from pooled randomised trials and a large observational study show that thrombolysis can probably be done safely in patients given vitamin-K antagonists if the international normalised ratio is less than 1·7, although bleeding risk is slightly raised. Almost no data are available for the safety of alteplase in patients with atrial fibrillation who have been given novel oral anticoagulants (NOAC) for stroke prevention. Some coagulation parameters could help to identify patients treated with NOAC who might be eligible for thrombolysis. Thrombectomy can be done in patients given antiplatelets and probably in those given anticoagulants; however, conclusions about anticoagulants are based on findings from observational studies with small patient numbers.
authors.affiliation: Department of Neurology and Stroke Centre, University Hospital Essen, Essen, Germany. h.diener@uni-essen.de
authors.forename: Hans-Christoph
authors.initials: HC
authors.lastname: Diener
authors.forename: Christian
authors.initials: C
authors.lastname: Foerch
authors.forename: Hanno
authors.initials: H
authors.lastname: Riess
authors.forename: Joachim
authors.initials: J
authors.lastname: Röther
authors.forename: Gerhard
authors.initials: G
authors.lastname: Schroth
authors.forename: Ralph
authors.initials: R
authors.lastname: Weber
mesh_terms: D000818:Animals; D000925:Anticoagulants / Q000627:therapeutic use; D002545:Brain Ischemia / Q000150:complications / Q000188:drug therapy*; D002543:Cerebral Hemorrhage / Q000209:etiology; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D010960:Plasminogen Activators / Q000009:adverse effects / Q000627:therapeutic use; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000188:drug therapy* / Q000209:etiology; D017131:Thrombectomy / Q000009:adverse effects / Q000379:methods*; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000009:adverse effects / Q000627:therapeutic use; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D014859:Warfarin; D010960:Plasminogen Activators; D010959:Tissue Plasminogen Activator