Intravenous Thrombolysis With Recombinant Tissue-Type Plasminogen Activator in a Stroke Patient Receiving Dabigatran Anticoagulant After Antagonization With Idarucizumab.
OBJECTIVE
Therapeutic options for acute ischemic stroke patients presenting on effective anticoagulation are limited. Idarucizumab, a humanized, monoclonal antibody fragment for immediate reversal of dabigatran, may allow this subgroup of orally anticoagulated patients to regain eligibility for thrombolysis.


METHODS
We report the first successful acute antagonization of dabigatran by idarucizumab before intravenous thrombolysis with recombinant tissue-type plasminogen activator.


RESULTS
Idarucizumab was given to a 76-year-old male patient on dabigatran ≈3.5 hours after his last dose. Neurological status on admission was NIHSS (National Institutes of Health Stroke Scale) 11. Recombinant tissue-type plasminogen activator was initiated immediately after dabigatran reversal. The patient was discharged with a favorable outcome of NHISS 1 on day 7. No complications were observed.


CONCLUSIONS
This case represents a new therapeutic paradigm. It is further supported by in vitro data showing no nonspecific interactions of idarucizumab with recombinant tissue-type plasminogen activator-induced thrombolysis. Thus, patients effectively anticoagulated with dabigatran who were previously contraindicated for thrombolytic therapy in this situation may now receive treatment because of the ability to rapidly reverse the anticoagulant activity of dabigatran with idarucizumab.
From the Department of Neurology, Klinikum Altenburger Land GmbH, Altenburg, Germany (J.B., A.S., T.H.); and Medical Affairs Germany, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim am Rhein, Germany (C.C.E.). joerg.berrouschot@klinikum-altenburgerland.de.
Jörg
J
Berrouschot
From the Department of Neurology, Klinikum Altenburger Land GmbH, Altenburg, Germany (J.B., A.S., T.H.); and Medical Affairs Germany, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim am Rhein, Germany (C.C.E.).
Anett
A
Stoll
From the Department of Neurology, Klinikum Altenburger Land GmbH, Altenburg, Germany (J.B., A.S., T.H.); and Medical Affairs Germany, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim am Rhein, Germany (C.C.E.).
Theresa
T
Hogh
From the Department of Neurology, Klinikum Altenburger Land GmbH, Altenburg, Germany (J.B., A.S., T.H.); and Medical Affairs Germany, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim am Rhein, Germany (C.C.E.).
Christoph Cyrill
CC
Eschenfelder
D000368:Aged; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use*; D000931:Antidotes / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications; D002545:Brain Ischemia / Q000150:complications / Q000188:drug therapy*; D000069604:Dabigatran / Q000037:antagonists & inhibitors* / Q000627:therapeutic use; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000178:diet therapy; D006801:Humans; D006973:Hypertension / Q000150:complications; D020244:Infarction, Middle Cerebral Artery / Q000209:etiology; D008297:Male; D010291:Paresis / Q000209:etiology; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000627:therapeutic use; D020127:Recovery of Function; D012720:Severity of Illness Index; D015912:Thrombolytic Therapy; D019851:Thrombophilia / Q000188:drug therapy / Q000209:etiology; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*
D061067:Antibodies, Monoclonal, Humanized; D000931:Antidotes; D011994:Recombinant Proteins; C000594745:idarucizumab; D010959:Tissue Plasminogen Activator; D000069604:Dabigatran
anticoagulants; antidotes; dabigatran; idarucizumab; stroke