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Intravenous alteplase and endovascular clot retrieval following reversal of dabigatran with idarucizumab
  1. Dominic M Tse1,
  2. Laura Young2,
  3. Annemarei Ranta3,4,
  4. P A Barber1,5
  1. 1 Department of Neurology, Auckland City Hospital, Auckland, New Zealand
  2. 2 Department of Haematology, Auckland City Hospital, Auckland, New Zealand
  3. 3 Department of Neurology, Capital and Coast District Health Board, Wellington, New Zealand
  4. 4 Department of Medicine, University of Otago, Dunedin, New Zealand
  5. 5 Department of Medicine, University of Auckland, Auckland, New Zealand
  1. Correspondence to Professor P A Barber, Department of Neurology, Auckland City Hospital, Grafton, Auckland 1023, New Zealand; ABarber{at}

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Dabigatran etexilate (dabigatran) is a direct thrombin inhibitor that has been shown to prevent stroke in patients with atrial fibrillation. Idarucizumab is a humanised monoclonal antibody fragment developed to reverse the anticoagulant effects of dabigatran. Idarucizumab binds dabigatran 350 times more avidly than dabigatran binds thrombin, and completely reverses dabigatran’s biological activity within a few minutes.1 To date there have been only a handful of patients in whom dabigatran have been reversed with idarucizumab prior to treatment with intravenous alteplase, and none prior to endovascular clot retrieval.2 3


All New Zealand patients treated with alteplase must be entered into a national database, and this has noted whether idarucizumab was used prior to alteplase or clot retrieval since 2016. All patients treated with dabigatran and presenting within the 4.5-hour alteplase, or 6-hour endovascular clot retrieval treatment windows, had blood samples taken for thrombin clotting time (TCT) and activated partial thromboplastin time (APTT). Idarucizumab 5g was given intravenously if either the APTT or TCT was prolonged above the normal range for …

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  • Contributors DMYT acquired the data and drafted the manuscript; LY, AR and PAB were involved in critical review and approval of manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.