Intravenous Thrombolysis in a Stroke Patient Receiving Rivaroxaban
An 83-year-old man with a history of nonvalvular atrial fibrillation, heart failure (NYHA class III), biventricular pacing, hypercholesterolemia, arterial hypertension and two previous strokes 4 months and 4 years before admission presented with acute right hemiparesis and dysarthria that lasted for 2 h. The patient was treated with rivaroxaban at a reduced dose of 15 mg once daily. The last intake of rivaroxaban was 21 h before symptom onset.\nOn admission, blood pressure was 114/76 mm Hg and the NIHSS score equaled 9. Blood tests showed an increased partial thromboplastin time (41.9 s; normal 23-36), a normal thrombin time (18.9 s; normal 14-21) and a slightly elevated international normalized ratio (INR: 1.41; normal 0.85-1.18). Rivaroxaban plasma concentration was below the detection limit, and anti-factor Xa activity (COATEST®; Chromogenix, Lexington, Mass., USA) was absent. Platelet count was normal, whereas renal function was impaired (creatinine 132 μmol/l, normal <103; creatinine clearance according to the Cockcroft-Gault formula 28.2 ml/min). Cranial CT and CT-angiography revealed no early signs of cerebral ischemia or ICH, and the large brain vessels were patent. Since anti-factor Xa activity was absent and the INR was <1.7 [], the patient received IVT with rtPA at 0.9 mg/kg (total dose 50 mg) 210 min after stroke onset. Shortly afterwards, the neurological status rapidly improved. On a follow-up blood examination, partial thromboplastin time (52.5 s) and INR (1.33) continued to be slightly elevated, while renal function was still impaired (creatinine clearance 27.8 ml/min). ICH could be ruled out by a follow-up cranial CT. Ultrasound examination of the cerebral vasculature was normal, as was echocardiography. Twenty-four hours after thrombolysis, creatinine clearance had increased above 30.0 ml/min, and treatment with dabigatran 110 mg twice daily was initiated. The NIHSS score at discharge was 1.