Dilemma of indication for thrombolysis in a patient with acute ischemic stroke treated with a novel oral anticoagulant.

Increasing age of the population is associated with a higher rate of cerebrovascular diseases, and every sixth stroke is the consequence of atrial fibrillation. In atrial fibrillation, vitamin K antagonists are routinely used to prevent cardioembolic strokes. Thrombolytic treatment recombinant tissue-type plasminogen activator (rt-PA) has established efficacy in acute ischemic stroke, but in anticoagulated patients, its use is contraindicated for those with an international normalized ratio of 1.7 or more. Recently, novel oral anticoagulants have become available. With conventional methods, however, it is difficult to assess the coagulation status of patients on these new treatments. We report the case of a patient treated with dabigatran who developed acute ischemic stroke and was considered for thrombolysis. Because of the prolonged thrombin time (TT), thrombolysis was not performed. Repeated coagulation tests 5 days after stroke, with unchanged anticoagulant (dabigatran) treatment, found 2-fold higher TT and activated partial thromboplastin time (APTT) compared with the values found in the acute stage. Routine coagulation tests (TT and APTT) do not reliably reflect the coagulation features of a patient; therefore, there is an urgent need to develop reliable biomarkers and an adequate guideline to help decision making regarding thrombolysis in those who develop their strokes while on one of these new oral anticoagulants.