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A case report of parenchymal hematoma after intravenous thrombolysis in a rivaroxaban-treated patient: Is it a true rivaroxaban hemorrhagic complication?

Abstract To date, the only treatment approved for acute ischemic strokes is thrombolysis. Whether intravenous thrombolysis may be safe in patients taking direct oral anticoagulants (DOACs) is currently a matter of debate.
PMID
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Authors

Mayor MeshTerms
Keywords
Journal Title medicine
Publication Year Start




PMID- 29390574
OWN - NLM
STAT- MEDLINE
DCOM- 20180212
LR  - 20180212
IS  - 1536-5964 (Electronic)
IS  - 0025-7974 (Linking)
VI  - 96
IP  - 51
DP  - 2017 Dec
TI  - A case report of parenchymal hematoma after intravenous thrombolysis in a
      rivaroxaban-treated patient: Is it a true rivaroxaban hemorrhagic complication?
PG  - e9435
LID - 10.1097/MD.0000000000009435 [doi]
AB  - RATIONALE: To date, the only treatment approved for acute ischemic strokes is
      thrombolysis. Whether intravenous thrombolysis may be safe in patients taking
      direct oral anticoagulants (DOACs) is currently a matter of debate. PATIENT
      CONCERNS: A 74-year-old woman, who was on rivaroxaban 20 mg/d for nonvalvular
      atrial fibrillation, was admitted to our stroke unit with left-sided hemiparesis 
      and aphasia. The onset of neurologic deficits had occurred 5 hours after the last
      rivaroxaban dose. DIAGNOSIS: An acute ischemic stroke was diagnosed.
      INTERVENTIONS: The patient was administered thrombolytic treatment with
      intravenous recombinant tissue plasminogen activator (r-TPA) 3 hours and 20
      minutes after symptoms onset. Seven hours post-r-TPA treatment, the neurological 
      deficit had worsened, and a type I intraparenchymal hematoma was detected on a
      computed tomography brain scan. OUTCOMES: The clinical/neuroradiological picture 
      improved significantly in the following days. The patient was discharged to a
      rehabilitation facility after 3 weeks. LESSONS: In this case, factor ten
      activated (Xa) inhibitor, rivaroxaban might have increased the risk of
      hemorrhagic transformation of the ischemic stroke. However, this risk was
      overweighed by the benefit of thrombolysis, as the patient's clinical condition
      had improved significantly in the following weeks. The current guidelines
      discourage the use of thrombolytic treatment in patients with DOACs administered 
      within the last 24(48) hours. However, the case reported herein and other world
      experiences, even though limited, suggest that an ongoing DOAC medication could
      no longer be considered a barrier to r-TPA treatment which may be a reasonable
      and valuable option, at least in selected acute stroke patients taking factor Xa 
      inhibitors.
CI  - Copyright (c) 2017 The Authors. Published by Wolters Kluwer Health, Inc. All
      rights reserved.
FAU - Rota, Eugenia
AU  - Rota E
AD  - Neurology Unit.
FAU - Bruzzone, Gianluca
AU  - Bruzzone G
AD  - Neurology Unit.
FAU - Agosti, Sergio
AU  - Agosti S
AD  - Cardiology Unit.
FAU - Pastorino, Roberto
AU  - Pastorino R
AD  - Radiology Unit, San Giacomo Hospital, Novi Ligure, Alessandria.
FAU - Morelli, Nicola
AU  - Morelli N
AD  - Neurology and Radiology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy.
LA  - eng
PT  - Case Reports
PT  - Journal Article
PL  - United States
TA  - Medicine (Baltimore)
JT  - Medicine
JID - 2985248R
RN  - 0 (Factor Xa Inhibitors)
RN  - 0 (Recombinant Proteins)
RN  - 9NDF7JZ4M3 (Rivaroxaban)
RN  - EC 3.4.21.68 (Tissue Plasminogen Activator)
SB  - AIM
SB  - IM
MH  - Aged
MH  - Factor Xa Inhibitors/*adverse effects/therapeutic use
MH  - Female
MH  - Hematoma, Subdural, Intracranial/*chemically induced
MH  - Humans
MH  - Recombinant Proteins
MH  - Rivaroxaban/*adverse effects/therapeutic use
MH  - Stroke/*drug therapy
MH  - Thrombolytic Therapy/*adverse effects/methods
MH  - Tissue Plasminogen Activator/adverse effects/therapeutic use
PMC - PMC5758276
EDAT- 2018/02/03 06:00
MHDA- 2018/02/13 06:00
CRDT- 2018/02/03 06:00
PHST- 2018/02/03 06:00 [entrez]
PHST- 2018/02/03 06:00 [pubmed]
PHST- 2018/02/13 06:00 [medline]
AID - 10.1097/MD.0000000000009435 [doi]
AID - 00005792-201712220-00161 [pii]
PST - ppublish
SO  - Medicine (Baltimore). 2017 Dec;96(51):e9435. doi: 10.1097/MD.0000000000009435.