Ischemic stroke in patients on dabigatran: a role for rescue thrombectomy?

Abstract

To the Editor The development of an acute ischemic stroke (AIS) despite anticoagulant therapy has been called an ‘anticoagulation failure’ (1). In their case report, Tabata et al. (2) reviewed the literature pertaining to the use of intravenous thrombolysis in patients on the new oral anticoagulant (NOAC), dabigatran, presenting with AIS. Their article illustrates the challenges that clinicians face in trying to treat patients in situations where there are no evidence-based recommendations. Given the rapidly growing popularity of the direct oral anticoagulants, stroke neurologists are likely to be confronted with scenarios of this sort more frequently in the near future. All in all, the available case reports about thrombolysis in stroke patients on dabigatran paint a mixed picture, and indicate that there is still a significant risk of bleeding. In a recent review, Epple and Steiner expertly discussed the practical issues inherent to this therapeutic dilemma (1). The authors advised caution and concluded that “it is unlikely that patients on NOAC who experience an AIS would be suitable for thrombolysis, unless they have missed their NOAC dose for the last 24-48 hours”. For this reason, we would like to point to a different treatment option. We and others (3, 4) have shown that neurointerventional recanalization might constitute a promising treatment alternative in centers with high neuroradiological expertise. An endovascular approach using mechanical clot extraction devices does not expose patients to thrombolytic agents. Hence, a lower risk of intracranial hemorrhage is conceivable. All three cases reported so far showed a good clinical outcome. An asymptomatic intimal tear with transient extravasation of contrast medium was deemed likely in the first patient, and represents the only complication reported. As rightly commented by Hankey (5), such a “simple solution” remains unproven in terms of whether it is a safe and effective alternative to thrombolysis. Nevertheless, physicians occasionally face complex clinical situations and patient subgroups for which information derived from controlled clinical trials cannot be applied. We believe that case reports like those by Moey et al. and our group could form the basis of future observational studies. In our opinion, endovascular revascularization might emerge as a valuable treatment option for AIS patients on treatment with dabigatran, and possibly other novel oral anticoagulants.