Pikija S, et al. – This systematic review was performed to evaluate current knowledge about dabigatran reversal prior to systemic reperfusion treatment in acute ischemic stroke. In acute ischemic stroke, experience with idarucizumab administration prior to tissue plasminogen activator treatment was limited. In less severe stroke syndromes and short time windows, initial clinical experience seemed favorable. To confirm safety, including bleeding complications and the risk of thrombosis, larger cohorts were needed.

• Up to June 2017, the researchers conducted a systematic review of all published cases of intravenous tissue plasminogen activator treatment following the administration of a dabigatran antidote and added 5 unpublished cases of their own.
• Clinical and radiological outcomes, symptomatic post-thrombolysis intracranial hemorrhage, and other serious systemic bleeding were examined.
• Allergic reaction to idarucizumab, and venous thrombosis in the post-acute phase were included as the additional endpoints.

• With a median age of 76 years (interquartile range 70–84), 21 patients (71% male) were identified.
• At baseline, the median National Institute of Health Stroke Scale score was 10 (n = 20, interquartile range 5–11) and 18/20 patients (90%) had mild or moderate stroke severity.
• 155 min was the time from symptom onset to start of tissue plasminogen activator (n = 18, interquartile range 122–214).
• In 3/19 patients (16%), the outcome was unfavorable.
• As a result of a symptomatic post-thrombolysis intracranial hemorrhage, there was 1 fatality, and 2 patients experienced an increase in the National Institute of Health Stroke Scale compared with baseline.
• In this study, 1 patient had a recurrent stroke.
• There were no systemic bleeding, venous thrombosis, or allergic reactions.