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Intravenous thrombolysis in patients with ischemic stroke and DOAC intake

Thomas Meinel, MD, Bern University Hospital, and University of Bern, Bern, Switzerland, discusses the controversies surrounding the use of intravenous thrombolysis in patients with ischemic stroke and recent direct oral anticoagulant (DOAC) intake. Currently, 1 in 6 stroke patients has a history of oral anticoagulation, with this percentage likely to increase as novel indications for DOACs are uncovered. Guidelines from the European Stroke Organisation and the American Heart Association strongly recommend against thrombolysis within 48 hours after last DOAC intake. With many of these patients presenting in the early time window and otherwise qualifying for thrombolysis, this topic remains a significant clinical question. Dr Meinel highlights a retrospective cohort study including 830 patients with ischemic stroke on DOAC therapy who received intravenous thrombolysis and over 19000 patients without prior DOAC therapy. No evidence of harm was seen in the DOAC arm, with patients half as likely to develop symptomatic intercranial hemorrhage and higher odds of independent outcome at 3 months, compared to controls. Selecting patients based on DOAC level-measurements or prior reversal-treatment also seemed to result in safe thrombolysis. This interview took place at the ESOC 2022 congress in Lyon, France.