Direct Oral Anticoagulant Plasma Levels for the Management of Acute Ischemic Stroke

Marsch A, Macha K, Siedler G, Breuer L, Strasser E, Engelhorn T, Dörfler A, Schwab S, Kallmünzer B (2019)

Publication Type: Journal article

Publication year: 2019

Journal

Cerebrovascular Diseases Karger Publishers

Abstract

Introduction: The management of acute ischemic stroke in patients on direct oral anticoagulants (DOACs) is challenging. However, the substance-specific plasma level could guide treatment decisions on recanalization therapies. We present a plasma-level-based protocol for emergency treatment of stroke patients on oral anticoagulants. Bleeding complications and clinical outcome for patients on DOACs are reported and compared to patients on vitamin K antagonists (VKAs). Methods: In patients with acute ischemic stroke and suspected use of DOACs within 48 h prior to hospital admission, plasma levels were measured using the calibrated Xa-activity (apixaban, edoxaban, rivaroxaban) or the Hemoclot®-assay (dabigatran). Levels <50 ng/mL were supportive for thrombolysis, while high values >100 ng/mL excluded patients from recombinant tissue plasminogen activator use. For patients on VKAs, the cutoff was set at international normalized ratio of 1.7. Endovascular thrombectomy of a large vessel occlusion was performed independently from coagulation testing. Consecutive patients were included in an observational registry. Results: Five hundred and twenty-two patients (261 on VKAs and 261 on DOACs) were included. Thirty patients (11.5%) on VKAs and 24 (9.2%) on DOACs received thrombolysis, followed by mechanical thrombectomy in 10 and 14 patients, respectively. Seventeen patients in each group received thrombectomy only. Symptomatic intracranial hemorrhage associated with thrombolysis occurred in 1 patient on VKA (3.3%) and 1 on DOAC (4.2%; p = 0.872). The turnaround time of specific assays did not show a significant delay in comparison to standard coagulation parameters. Conclusion: DOAC plasma levels could support decisions on emergency treatment of ischemic stroke. Systemic thrombolysis below suggested thresholds appears preliminary feasible and safe without an excess in bleeding complications.

Authors with CRIS profile

Armin Marsch Department of Neurology Kosmas Macha Medizinische Fakultät Gabriela Siedler Department of Neurology Erwin Strasser Medizinische Fakultät Tobias Martin Engelhorn Department of Neuroradiology Arnd Dörfler Department of Neuroradiology Stefan Schwab Lehrstuhl für Neurologie Bernd Kallmünzer Department of Neurology

How to cite

APA:

Marsch, A., Macha, K., Siedler, G., Breuer, L., Strasser, E., Engelhorn, T.,... Kallmünzer, B. (2019). Direct Oral Anticoagulant Plasma Levels for the Management of Acute Ischemic Stroke. Cerebrovascular Diseases. https://doi.org/10.1159/000502335

MLA:

Marsch, Armin, et al. "Direct Oral Anticoagulant Plasma Levels for the Management of Acute Ischemic Stroke." Cerebrovascular Diseases (2019).

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