Our single-center experience with intravenous recombinant tissue plasminogen activator, mechanical thrombectomy, and bridging therapy in acute ischemic stroke patients using non-vitamin k antagonist oral anticoagulants: Efficacy and safety outcomes

Introduction: The safety of intravenous recombinant tissue plasminogen activator (IV tPA) and mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients taking non-vitamin K antagonist oral anticoagulants (NOACs) remains controversial. This study aimed to evaluate the clinical, angiographic, and safety outcomes of patients who had an AIS while taking a NOAC for atrial fibrillation (AF) and received reperfusion therapy.Methods: Twenty-two patients who presented with AIS while taking a NOAC (apixaban, rivaroxaban, edoxaban) for AF and received acute reperfusion therapy were retrospectively reviewed. Patients were grouped as IV tPA only (n=11), MT only (n=4), and bridging therapy (IV tPA + MT, n=7). The primary safety outcomes were symptomatic intracranial hemorrhage (sICH) and hemorrhagic transformation (HT); the primary efficacy outcomes were successful recanalization (mTICI 2b/3), functional independence at day 90 (mRS 0–2), and mortality (mRS 6).Results: The mean age of the patients was 74.6 ± 7.4 years, and 72.7% were women. The median NIHSS was 11.0 [IQR: 10.0–14.0], and the rate of large vessel occlusion (LVO) was 68.2% (n=15). The NOACs were apixaban (n=8), rivaroxaban (n=8), and edoxaban (n=6) (72.7% at the standard dose). IV tPA was given to all 13 patients whose last dose had been taken 12–24 hours earlier. Of the 21 patients with radiological follow-up, 3 (14.3%) developed sICH; all of them were in the bridging group (3/7, 42.9%; all had proximal LVO and a severe initial deficit). No sICH was seen in the IV tPA–only or MT-only groups. The frequency of hemorrhagic transformation in the whole cohort was 19.0% (4/21). Successful recanalization (mTICI 2b/3) was achieved in all patients who underwent MT and had available data (100%, 9/9). Functional independence at day 90 was recorded in 9/20 patients in the whole cohort (IV tPA only 6/10, MT only 1/3, bridging 2/7), and mortality in 6/20.Discussion/Conclusion: In this study, no sICH was observed after IV tPA in patients whose last NOAC dose had been taken more than 12 hours earlier. The fact that the patients who developed sICH in the bridging group had a severe initial neurological deficit and a proximal LVO suggests that bleeding risk may be influenced not only by anticoagulant use but also by initial stroke severity and reperfusion-related factors. In conclusion, this study supports the view that NOAC use does not significantly increase bleeding risk and that IV tPA treatment may be safe in patients who have an AIS while taking a NOAC.Keywords: