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Letter
Intravenous thrombolysis in stroke after dabigatran reversal with idarucizumab: case series and systematic review
  1. David Giannandrea1,
  2. Carla Caponi2,
  3. Anna Mengoni3,
  4. Michele Romoli4,
  5. Claudia Marando1,
  6. Antongiulio Gallina1,
  7. Erica Marsili1,
  8. Elisa Sacchini1,
  9. Sara Mastrocola1,
  10. Chiara Padiglioni1,
  11. Tatiana Mazzoli1,
  12. Silvia Cenciarelli1,
  13. Stefano Ricci1
  1. 1 Neurology Unit–Stroke Unit, Gubbio/Gualdo Tadino and Città di Castello Hospitals, USL Umbria 1, Perugia, Italy
  2. 2 Internal Medicine Unit, Gubbio/Gualdo Tadino Hospital, USL Umbria 1, Perugia, Italy
  3. 3 Cardiology and Cardiovascular Physiopathology, S. Maria della Misericordia Hospital, Perugia, Italy
  4. 4 Neurology Clinic, University of Perugia, S. Maria della Misericordia Hospital, Perugia, Italy
  1. Correspondence to Dr David Giannandrea, Gubbio and Gualdo Tadino Hospital, Largo Unità d’Italia, Perugia 06024, Italy; david.giannandrea{at}uslumbria1.it

https://doi.org/10.1136/jnnp-2018-318658

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    Background

    Idarucizumab can reverse the effect of the direct thrombin inhibitor dabigatran,1 a non-vitamin K oral anticoagulant (NOAC) available for primary and secondary prevention of cardioembolic stroke due to non-valvular atrial fibrillation. Ischaemic stroke may happen despite ongoing anticoagulation, a contraindication to intravenous thrombolysis (IVT).2 Thus, patients with ischaemic stroke while on dabigatran might be eligible for anticoagulation reversal with idarucizumab to allow IVT. Here, we report our case series and provide a systematic review to define outcomes of such treatment algorithm.

    Methods

    Case series of patients undergoing IVT after dabigatran reversal was identified from our stroke registry (online supplementary file 1). Systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines3 and specified protocol (PROSPERO: http://www.crd.york.ac.uk/PROSPERO, registration no. CRD42017060274) (online supplementary file 2). Search strategy, performed on Cochrane Library, MEDLINE, EMBASE and PubMed, can be found in online supplementary file 1.

    Supplemental material

    [jnnp-2018-318658-supp1.pdf]

    Supplemental material

    [jnnp-2018-318658-supp2.pdf]

    Data extraction and outcome assessment

    All available data were collected (online supplementary file 1). According to National Institute of Health Stroke Scale (NIHSS) total score, stroke were divided into mild (1–4), moderate (5–15), moderate to severe (16–20) and severe (21–42 4). Unfavourable outcome was defined as an increase in NIHSS score or death. Additional outcomes included modified Rankin Scale (mRS) at follow-up, symptomatic intracerebral haemorrhage, systemic bleeding, allergic reactions to idarucizumab, recurrent stroke and venous thrombosis during post-acute phase.

    Statistical analysis

    Statistical analysis was performed with R software using …

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    Footnotes

    • DG and MR contributed equally.

    • Contributors DG, SR and SC conceived the idea, planned and designed the study. DG, CC, AM and MR wrote the first draft. CM and AG evaluated and wrote the clinical cases. DG and SM designed the search strategy. DG, ES, AM and MR evaluated the literature and selected the papers. DG, SR and CC planned the data extraction. SM, AM and MR extracted and analysed data. DG and MR revised the draft and updated the manuscript. CP, SC, TM and SR provided critical insights. All authors have approved and contributed to the final version of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent Not required.

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