Christian Boehme, MD, PhD
Department of Neurology
Medical University of Innsbruck, Innsbruck, Austria
Twitter handle: @chris7ianb

Jan Purrucker highlights the fact that despite direct oral anticoagulant (dOAC) treatment, the annual risk of ischaemic stroke is 1.34% which doubles in secondary prevention. Guidelines recommend not giving thrombolysis in patients with acute ischaemic stroke and recent (< 48 hours) dOAC intake.

Prior research including a retrospective cohort (Get With the Guidelines Stroke hospitals) showed no difference in safety outcomes including mortality in roughly 2200 patients who were thrombolysed despite a recent dOAC intake (aOR 0.88, 95%CI 0.70-1.10).

In an international multicentre retrospective cohort study, the authors included patients with ischaemic stroke and prior dOAC therapy with a confirmed last intake < 48 hours or unknown last intake, who received intravenous thrombolysis (IVT). The patients were compared to those without prior dOAC therapy and received IVT. The main outcome was symptomatic intracerebral haemorrhage (sICH) within 36 hours after IVT administration, the secondary outcome was functional independence at 3 months (mRS 0-2).

All in all, roughly 20,000 patients were included, of which n=832 had a recent dOAC intake. Of all patients who received IVT after recent dOAC intake, 30% received dOAC reversal, 27% were selected on dOAC levels, and 43% had no reversal or dOAC level check.

Concerning the primary outcome, the unadjusted rate of sICH in the dOAC group was 2.5% (95%CI, 1.6%-3.8%) versus 4.5% (95%CI 4.2%-4.8%) in the non-dOAC group. After adjustment for severity of stroke and other baseline sICH predictors, patients who received IVT with recent dOAC treatment had lower odds of developing sICH with an adjusted OR of 0.49 (95%CI 0.30-0.80).

Regarding the secondary outcome, there was no difference between functional independence in both groups 3 months after the index event.
Jan Purrucker mentions the observational study design, some baseline differences in the two groups and a possible selection bias as limitations to the study.

To summarize, the authors found no evidence for harm of IVT in patients with acute ischaemic stroke with recent dOAC intake. The authors conclude that the results support the removal of recent dOAC treatment as a contraindication for IVT in acute ischaemic stroke.


  1. TR Meinel et al: Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants | Emergency Medicine | JAMA Neurology | JAMA Network
  2. IVT in patients on recent DOAC: Press presentation by Jan Purrucker