Intravenous Thrombolysis for Stroke in Patients Receiving Oral Factor Xa Inhibitors

We present 3 patients who were taking oral direct factor Xa inhibitors (ODFXIs) within 24 hours prior to receiving intravenous recombinant tissue plasminogen activator (IV rtPA) for acute ischemic stroke (AIS). Two patients were on Rivaroxaban (20 mg once daily) and one on Apixaban (2.5mgtwice daily). All 3 received IV rtPA within 3 hours of symptom onset. Their aPPT, PT and INR levels were within normal ranges. They all received the last dose of the ODFXI within the last 24 hours prior to IV rtPA administration. One patient underwent mechanical thrombectomy of a large vessel clot after IV rtPA. None had intracranial hemorrhage (ICH) on 24 hour head CT post IV rtPA. They all had acute infarcts on their brain MRI, diffusion weighted image. Although we had a very low number of patients in our case series, our findings suggest that neither IV rtPA nor the combination of IV rtPA and intra-arterial thrombolysis increases the risk of ICH in AIS patients who are taking ODFXIs and their coagulation parameters are within normal range.