Ischemic stroke in an elderly patient on apixaban

Abstract

Mr. LPH, an 86 year old patient taking warfarin for atrial fibrillation (AF) is admitted for a vertebral fracture. His calculated CHADSs score was of 6. A suboptimal control of diabetes was detected. Metformin and glyburide were increased. Four days after discharge, Mr. LPH was readmitted due to diarrhea and hyperglycemia. Metformin was discontinued. Glyburide dose was adjusted. INR dosage results fluctuated during hospital stay over and under therapeutic values. Warfarin was discontinued and apixaban 2.5 mg twice daily was started. Mr. LPH was later admitted for a pulmonary severe sepsis. His infection was complicated by two AF episodes. After the last episode, Mr. LPH presented dysarthria, facial asymmetry and left hemiparesis. On the cerebral scan, we observed a right Sylvian artery stroke. Conclusion: In this case, the 2.5 mg apixaban dose was used and may explain the stroke. It occurred after two consecutive AF episodes making it the most likely cause. The choice of the low drug dosage may have been in response to caution and patient frailty. The patient was stable on warfarin for the past 14 years and the fluctuating INR episode can be explained by drug interaction. Glyburide may enhance the anticoagulation effect of warfarin.