Table 2
American Heart/Stroke Association65 The use of intravenous alteplase in patients taking direct thrombin inhibitors or direct factor Xa inhibitors has not been firmly established but may be harmful. Intravenous alteplase should not be administered to patients taking direct thrombin inhibitors or direct factor
Xa inhibitors unless laboratory tests such as aPTT, INR, platelet count, ecarin clotting time, thrombin time or appropriate direct factor Xa activity assays are normal or the patient has not received a dose of these agents for >48 hours (assuming normal renal metabolising function).
Japanese consensus statement38 For dabigatran IVT is not recommended if aPTT >1.5 times or last dose is <4 hours. In this case, IVT can be considered after intravenous administration of idarucizumab.
For factor Xa inhibitors IVT is not recommended if INR exceeds at least 1.7.
IVT is not recommended if the time of the last dose is <4 hours
IVT can be considered if the time of the last dose is ≥4 hours and the level of INR is ≤1.7).
IVT after emergent reversal of prolonged INR using antidotes for other anticoagulants is not recommended.
ESO Karolinska Stroke Update 201866 Patients with acute ischaemic stroke under VKA or DOAC treatment with proven large vessel occlusion should be offered IVT (if feasible) and endovascular treatment (thrombectomy).
Thrombolysis allowed if DOAC plasma levels <30 ng/mL
If no DOAC plasma levels available, INR measurement using Hemochron Signature Elite is possible under specific circumstances
French Society of Vascular Neurology40 IVT if no intake >48 hours or DOAC level <50 ng/mL.
Conventional testing with TT, aPTT, PT and anti-Xa levels may be used (DOAC dependant). In the case of Dabigatran, reversal with Idaracizumab may also be considered.
Australian guidelines
(https://informme.org.au/en/Guidelines/Clinical-Guidelines-for-Stroke-Management)
Comparable to French Society of Vascular Neurology
  • aPTT, activated partial thrombin time; DOAC, direct oral anticoagulant; INR, international normalised ratio; IVT, intravenous thrombolysis; PT, prothrombine time; TT, thrombin time; VKA, vitamin K antagonist.