A 75-year-old woman was taken to the waiting room with a left-side hemiparez, a gaze of the eyes and a right-sided homonymous hemianopsia. These symptoms appeared 60 minutes before admission to the clinic. In the anamnesis: a non-valued form of atrial fibrillation, hypertension and ulcerative colitis. The patient took dabigatran at a dose of 220 mg / day. Results of the physical examination: arterial pressure 160/60 mmHg, severity of stroke 7 points on the scale NIHSS. In blood tests: significantly increased thrombin time (> 150 s, normal 14-21 s), APTT and MNO - within the reference values (35.5 s and 1.2, respectively). The concentration of dabigatran was 90 ng / ml, which indicates that the patient complies with the rules of drug use. Computed tomography of the brain was performed: early signs of cerebral ischemia or intracerebral hemorrhage were not detected (see Fig. 1a). In CT angiography, occlusion of the left posterior cerebral artery (hereinafter - ZMA) (see Figure 1b) and hypoplasia of the right vertebral artery were revealed. Other large vessels of the brain were completely preserved, and therefore endovascular intervention was not considered.
After receiving informed consent, the anticoagulant effect of dabigatran was eliminated with idaruzizumab, followed by intravenous thrombolysis using a recombinant tissue plasminogen activator at a dose of 0.9 mg / kg (total dose of 67 mg) 120 minutes after the onset of stroke symptoms. According to the data of repeated CT, intracranial hemorrhage was excluded, however, ischemic foci in the right sections of the bridge, thalamus and cerebellum were found (see Fig. 1c). The MRI was impossible to perform due to the installed artificial pacemaker.
Hospitalization was complicated by the development of aspiration pneumonia, in connection with which antibiotic therapy was prescribed (ceftriaxone 2 g / day IV.). No artificial ventilation was performed. Despite the thrombolysis performed, there was a tendency to aggravate the severity of the stroke, determined by the scale NIHSS (7 points at the time of hospitalization, 18 points at the time of discharge), mainly due to foci of heart attack in the bridge and thalamus. It is worth noting that with the subsequent additional CT check, signs of ischemia in the left AM pool were not detected,which indicates an extremely likely reperfusion.
The patient was referred to the rehabilitation and physiotherapy department. Anticoagulant therapy (rivaroxaban) was resumed after 4 weeks, during which the patient took acetylsalicylic acid at a dose of 100 mg / day. Three months later, there has been a significant improvement in the condition, but the patient still needs care.Discussion
Today, oral, direct-acting anticoagulants are increasingly prescribed for the primary and secondary prevention of embolic stroke in patients with atrial fibrillation. The higher efficacy and safety of dabigatran versus warfarin was demonstrated during the study RE-LY. However, against the background of the use of these drugs, the development of intracranial hemorrhages is possible, which causes the need for an antidote, with which it would be possible to quickly eliminate the anticoagulant effect, for example, before an emergency surgical intervention or in the case of hemorrhagic complications. Idarutsizumab - a drug based on chimeric monoclonal antibodies to dabigatran - became the first approved antidote.
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This clinical case illustrates the successful experience of using idarutsizumab in a patient with ischemic stroke, which allowed avoiding hemorrhagic complications after thrombolysis.