Letter to the editor Intravenous thrombolysis with recombinant tissue plasminogen activator in a stroke patient treated with apixaban Dear editor, Apixaban is increasingly used in clinical practice (1), but data on the bleeding risk in patients treated with recombinant tissue plasminogen activator (rt-PA) while taking apixaban are nonexistent. A 74-year-old right-handed man presented with abrupt onset of global aphasia. He was known with a partial right hemianopsia secondary to a left occipital intracerebral hemorrhage five-years earlier and with paroxysmal nonvalvular atrial fibrillation treated with apixaban 5 mg bid. The National Correspondence: Ann De Smedt*, Department of Neurology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium. E-mail: [email protected] Conflict of interest: None declared. DOI: 10.1111/ijs.12315

Institutes of Health Stroke Scale (NIHSS) score was 8. Noncontrast computed tomography (CT) of the brain showed no signs of acute intracranial pathology. Perfusion-CT revealed hypoperfusion in the territory of the left middle cerebral artery (Fig. 1a). An ostial stenosis of the left internal carotid artery was diagnosed on CT angiography (Fig. 1b). After informed consent by proxy, i.v. rt-PA therapy (0·9 mg/kg; total dose 81 mg) was administered at 4·5 h after symptom onset and 8·5 h after apixaban intake. Platelet count, prothrombin time, activated partial thromboplastin time, and fibrinogen levels were normal, as was creatinine clearance. The patient experienced an excellent recovery (NIHSS score 1) without signs of new infarction or intracranial hemorrhage on repeat CT. As apixaban is commonly used in patients with elevated stroke risk (1), therapeutic decision-making with regard to thrombolytic therapy may not uncommonly pose problems in the near future. Our case report illustrates that further study on the safety of rt-PA in this patient population is justified.

Ann De Smedt1,2*, Melissa Cambron1,2, Koenraad Nieboer3, Maarten Moens2,3,4, Robbert-Jan Van Hooff1,2, Laetitia Yperzeele1,2, Kristin Jochmans5, Jacques De Keyser1,2,6, and Raf Brouns1,2 1

Department of Neurology, Universitair Ziekenhuis Brussel, Brussels, Belgium 2 Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium 3 Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium 4 Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium 5 Department of Haematology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium 6 Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

Reference 1 Connolly SJ, Eikelboom J, Joyner C et al. Apixaban in patients with atrial fibrillation. N Engl J Med 2011; 364:806–17.

Fig. 1 (a) Perfusion-CT of the brain demonstrating a global prolongation of the Tmax in the territory of the left middle cerebral artery. (b) Volume rendering reconstruction of the CT angiography revealing the high-grade ostial stenosis of the left internal carotid artery (white arrow). CT, computed tomography.

© 2014 World Stroke Organization

Vol 9, October 2014, E31

E31