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Fatal Intracerebral Hemorrhage Associated with Administration of Recombinant Tissue Plasminogen Activator in a Stroke Patient on Treatment with Dabigatran

2011; Karger Publishers; Volume: 32; Issue: 6 Linguagem: Inglês

10.1159/000334578

1421-9786

Ignacio Casado Naranjo, Juan Carlos Portilla-Cuenca, Pedro Enrique Jiménez Caballero, María Luisa Calle Escobar, Raúl Mauricio Romero Sevilla,

Venous Thromboembolism Diagnosis and Management

We report a 62-year-old diabetic man who underwent electric cardioversion for NVAF detected 2 months previously, who refused to take acenocoumarol and who was pretreated only with enoxaparin for 1 month. After the procedure, he was treated with dabigatran 110 mg twice daily, as an off-label situation. Three hours after taking the third dose, he had an abrupt onset of aphasia and right hemiplegia. The National Institutes of Health Stroke Scale score was 18. A non-contrast head computed tomography (CT) scan was normal. Perfusion CT revealed a deficit of 1 2/3 of the left middle cerebral artery area ( fig. 1 a). His blood pressure was 142/78 mm Hg and his glycemic level was 233 mg/dl. Coagulation parameters were: platelet count 154 ! 10 9 /l (normal range 150–450), prothrombin time 14.6 s (normal range 8–14), international normalized ratio 1.29 (normal range 0.7–1.5), activated partial thromboplastin time 37.1 s (normal range 24–38) and fibrinogen level 293 mg/dl (normal range 200–450). After obtaining informed consent, thrombolysis was initiated at 190 min from stroke onset. The neurological status did not change. Twelve hours later, the patient became drowsy and fell into a coma shortly thereafter. A CT brain scan showed a lobar hemorrhage with mass effect ( fig. 1 b). Control coagulation parameters were normal. The patient was intubated and transferred to an intensive care unit where he died 2 days later. To the best of our knowledge, this is the first report to describe a fatal bleeding complication in a patient treated with dabigatran who had an IS and was treated with intravenous rtPA. Dabigatran is an oral anticoagulant that has been recently approved in Europe for prevention of stroke in patients with nonvalvular atrial fibrillation (NVAF), demonstrated to be equally safe or safer or at least as effective as warfarin [1] . In selected patients, we have the opportunity of thrombolysis treatment within 4.5 h after onset of ischemic stroke (IS) [2, 3] in order to minimize the risk of bleeding complications. Concomitant use of anticoagulants is a contraindication for administration of recombinant tissue plasminogen activator (rtPA) even if the international normalized ratio is ! 1.7 [4] . There is little information on bleeding risk in patients treated with rtPA while taking dabigatran [5, 6] . Published online: December 1, 2011