Intravenous thrombolysis for acute cerebral embolism during atrial fibrillation ablation: a case report and systematic review with meta-analysis

Introduction: Periprocedural stroke represents a clinically important complication of atrial fibrillation ablation, and effective anticoagulation remains essential for risk reduction. However, the use of intravenous thrombolysis in patients with acute ischemic stroke who have recently received novel oral anticoagulants remains controversial under certain clinical circumstances. This report described an uncommon case of radiofrequency ablation-related ischemic stroke treated with intravenous thrombolysis after dabigatran reversal with idarucizumab. In parallel, we conducted a systematic review and meta-analysis to evaluate the safety and outcomes of this treatment strategy. Methods: This study included analysis of an index case and a systematic review with meta-analysis. We report a 54-year-old patient who developed acute ischemic stroke shortly after radiofrequency catheter ablation for AF and was treated with intravenous thrombolysis after dabigatran reversal with idarucizumab. In parallel, a systematic literature search was conducted to identify observational studies, cohorts, and case series reporting idarucizumab-enabled thrombolysis in dabigatran-treated stroke patients. Data on intracranial hemorrhage (ICH), favorable functional outcome [modified Rankin Scale (mRS) 0-2], and mortality were extracted. Pooled estimates were calculated using random-effects meta-analysis of proportions, and comparative analyses with non-anticoagulated thrombolysis populations were performed using pooled risk ratios. Results: Neuroimaging confirmed an acute cerebral infarction in the left thalamus. The patient had been receiving dabigatran and was treated with intravenous idarucizumab followed by intravenous alteplase. Neurological deficits rapidly improved after thrombolysis, and the patient achieved a favorable recovery over 90 days of follow-up. Discussion: Findings from the systematic review and meta-analysis demonstrated low rates of intracranial hemorrhage, low mortality, and favorable functional outcomes comparable to standard thrombolysis populations. This case, together with accumulating evidence from the literature, supports the short-term safety and clinical effectiveness of idarucizumab-enabled intravenous thrombolysis in dabigatran-treated patients with periprocedural acute ischemic stroke. Therefore, early anticoagulant reversal followed by prompt reperfusion therapy may represent a feasible and safe therapeutic strategy in carefully selected patients.