title: Intravenous thrombolysis with recombinant tissue plasminogen activator in a stroke patient treated with rivaroxaban.
abstract: As limited amounts of data are available regarding thrombolytic therapy for patients taking novel oral anticoagulants, thrombolytic therapy is not recommended in such cases. Here, we report an acute stroke patient taking rivaroxaban who received intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA). An 80-year-old man with a history of nonvalvular atrial fibrillation, who had been receiving 10 mg of rivaroxaban showed abrupt onset of aphasia and right hemiparesis. National Institutes of Health Stroke Scale score was 10. Onset of neurologic deficits occurred 4 hours after the last dose of rivaroxaban. Clinical data on admission were as follows: blood pressure, 170/90 mm Hg; prothrombin time (PT), 22.6 seconds (control, 12.9 seconds); international normalized ratio, 2.03; activated partial thromboplastin time, 46 seconds (normal, 23-32 seconds); and creatinine level, 1.11 mg/dL. Magnetic resonance angiography revealed occlusion of the superior trunk of the left middle cerebral artery. Intravenous infusion of .6 mg/kg of rt-PA (total dose, 36 mg) was performed 6 hours after the last rivaroxaban administration with informed consent. The neurologic deficit improved during infusion of rt-PA. Repeat brain computed tomography showed left frontal cortical infarction without hemorrhagic changes. In the case of rivaroxaban, it is difficult to accurately determine the drug activity. As the anticoagulant activity of rivaroxaban can be estimated from its pharmacokinetics and PT, it is clinically important to obtain accurate information about the timing of medication and blood sampling.
authors.affiliation: Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan. Electronic address: hishi@yamaguchi-u.ac.jp.
authors.forename: Hideyuki
authors.initials: H
authors.lastname: Ishihara
authors.affiliation: Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan.
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Torii
authors.affiliation: Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan.
authors.forename: Hirochika
authors.initials: H
authors.lastname: Imoto
authors.affiliation: Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan.
authors.forename: Fumiaki
authors.initials: F
authors.lastname: Oka
authors.affiliation: Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan.
authors.forename: Hirokazu
authors.initials: H
authors.lastname: Sadahiro
authors.affiliation: Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan.
authors.forename: Michiyasu
authors.initials: M
authors.lastname: Suzuki
mesh_terms: D000369:Aged, 80 and over; D001281:Atrial Fibrillation / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D001777:Blood Coagulation / Q000187:drug effects; D002533:Cerebral Angiography / Q000379:methods; D038524:Diffusion Magnetic Resonance Imaging; D016903:Drug Monitoring / Q000379:methods; D065427:Factor Xa Inhibitors / Q000009:adverse effects / Q000493:pharmacokinetics / Q000627:therapeutic use*; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D007262:Infusions, Intravenous; D018810:Magnetic Resonance Angiography; D008297:Male; D009025:Morpholines / Q000009:adverse effects / Q000493:pharmacokinetics / Q000627:therapeutic use*; D011237:Predictive Value of Tests; D011517:Prothrombin Time; D011994:Recombinant Proteins / Q000008:administration & dosage; D012307:Risk Factors; D000069552:Rivaroxaban; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D013876:Thiophenes / Q000009:adverse effects / Q000493:pharmacokinetics / Q000627:therapeutic use*; D015912:Thrombolytic Therapy / Q000009:adverse effects; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D065427:Factor Xa Inhibitors; D005343:Fibrinolytic Agents; D009025:Morpholines; D011994:Recombinant Proteins; D013876:Thiophenes; D000069552:Rivaroxaban; D010959:Tissue Plasminogen Activator
keywords: Anticoagulant therapy; cardiogenic embolism; cerebral infarction; thrombolysis; tissue plasminogen activator