Dabigatran etexilate: management in acute ischemic stroke

Area of Science:

• Neurology
• Cardiology
• Pharmacology

Background:

• Long-term oral anticoagulation is crucial for preventing cardiac thromboembolism in nonvalvular atrial fibrillation.
• New oral anticoagulants, such as dabigatran, require clinicians to be familiar with their management.
• Direct thrombin inhibitors offer potent anticoagulation but pose unique clinical challenges.

Observation:

• A 54-year-old man on dabigatran experienced an acute ischemic stroke.
• Recombinant tissue plasminogen activator (rtPA) was contraindicated due to dabigatran use.
• Angiography revealed left middle cerebral artery occlusion; suction thrombectomy restored flow.

Findings:

• Dabigatran reversal was attempted with prothrombin complex concentrate and recombinant factor VIIa due to suspected intracranial hemorrhage.
• Coagulation studies showed minimal change in partial thromboplastin time post-reversal agent administration.
• Follow-up imaging confirmed no intracranial hemorrhage, and the patient was discharged on aspirin and warfarin.

Implications:

• This case highlights the complexities of managing acute stroke in patients treated with novel oral anticoagulants like dabigatran.
• It underscores the need for established protocols for dabigatran reversal in emergency situations.
• Understanding the efficacy and safety of reversal agents in this context is critical for clinical decision-making.