Recanalisation therapies for acute ischaemic stroke in patients on direct oral anticoagulants.

Seiffge, David J.; Meinel, Thomas; Purrucker, Jan Christoph; Kaesmacher, Johannes; Fischer, Urs; Wilson, Duncan; Wu, Teddy Y (2021). Recanalisation therapies for acute ischaemic stroke in patients on direct oral anticoagulants. Journal of neurology, neurosurgery, and psychiatry, 92(5), pp. 534-541. BMJ Publishing Group 10.1136/jnnp-2020-325456

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Direct oral anticoagulants (DOACs) have emerged as primary therapeutic option for stroke prevention in patients with atrial fibrillation. However, patients may have ischaemic stroke despite DOAC therapy and there is uncertainty whether those patients can safely receive intravenous thrombolysis or mechanical thrombectomy. In this review, we summarise and discuss current knowledge about different approaches to select patient. Time since last DOAC intake-as a surrogate for anticoagulant activity-is easy to use but limited by interindividual variability of drug pharmacokinetics and long cut-offs (>48 hours). Measuring anticoagulant activity using drug-specific coagulation assays showed promising safety results. Large proportion of patients at low anticoagulant activity seem to be potentially treatable but there remains uncertainty about exact safe cut-off values and limited assay availability. The use of specific reversal agents (ie, idarucizumab or andexanet alfa) prior to thrombolysis is a new emerging option with first data reporting safety but issues including health economics need to be elucidated. Mechanical thrombectomy appears to be safe without any specific selection criteria applied. In patients on DOAC therapy with large vessel occlusion, decision for intravenous thrombolysis should not delay thrombectomy (eg, direct thrombectomy or immediate transfer to a thrombectomy-capable centre recommended). Precision medicine using a tailored approach combining clinicoradiological information (ie, penumbra and vessel status), anticoagulant activity and use of specific reversal agents only if necessary seems a reasonable choice.

Item Type:

Journal Article (Review Article)

Division/Institute:

04 Faculty of Medicine > Department of Radiology, Neuroradiology and Nuclear Medicine (DRNN) > Institute of Diagnostic, Interventional and Paediatric Radiology
04 Faculty of Medicine > Department of Radiology, Neuroradiology and Nuclear Medicine (DRNN) > Institute of Diagnostic and Interventional Neuroradiology
04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurology

UniBE Contributor:

Seiffge, David Julian; Meinel, Thomas Raphael; Kaesmacher, Johannes and Fischer, Urs

Subjects:

600 Technology > 610 Medicine & health

ISSN:

1468-330X

Publisher:

BMJ Publishing Group

Language:

English

Submitter:

Maria de Fatima Henriques Bernardo

Date Deposited:

16 Feb 2021 08:27

Last Modified:

18 Apr 2021 01:34

Publisher DOI:

10.1136/jnnp-2020-325456

PubMed ID:

33542084

Uncontrolled Keywords:

cerebrovascular disease stroke

BORIS DOI:

10.48350/152014

URI:

https://boris.unibe.ch/id/eprint/152014

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