2025 Southeastern Residency Conference

Title: Intravenous Thrombolytic Therapy in Acute Ischemic Stroke with Chronic Anticoagulation Therapy   
Authors: Lauren Ducote, Jessica Starr, Nathan Pinner 
Objective: Assess bleeding outcomes in patients on chronic anticoagulation therapy who are treated with an intravenous thrombolytic for acute ischemic stroke.
Self-Assessment Question: Based on recent primary literature, patients on chronic direct oral anticoagulant (DOAC) therapy who receive intravenous thrombolysis for acute ischemic stroke are at increased risk for hemorrhagic stroke. (True/False) 
Background: Guidelines for stroke management recommend against giving intravenous thrombolytic therapy for an acute ischemic stroke if the patient has received anticoagulation within the previous 48 hours unless certain labs are assessed first. Recent literature suggests that there is not an increased risk of adverse bleeding events in patients who have taken anticoagulation recently compared to those who have not.  
Methods: This is a single center, retrospective study conducted on all patients admitted with an acute ischemic stroke who received intravenous thrombolytic therapy between May 1, 2013 to September 30, 2024. Patients were included if they were 18 years or older, admitted for an acute ischemic stroke, and received intravenous thrombolytic therapy. Patients were excluded if they received thrombolytic therapy for any other indication, had a hemorrhagic stroke on presentation, or received an endovascular intervention. The primary outcome is incidence of adverse bleeding within 24 hours of thrombolytic therapy which included the composite of intracranial hemorrhage, receipt of ≥2 units of packed red blood cells, or a >2 mg/dL fall in hemoglobin. Secondary outcomes include intracranial hemorrhage, receiving ≥2 units of packed red blood cells,>2 mg/dL fall in hemoglobin, DOAC reversal, length of stay, discharge disposition, and readmission within 30 days.
Results: Of the 265 patients reviewed, 245 patients were included. There were 11 patients taking oral anticoagulation and 234 patients not taking oral anticoagulation prior to admission. There was no statistically significant difference in adverse bleeding observed between the anticoagulation and no anticoagulation groups (18% vs. 12%, P=0.62). No statistical difference was observed in any of the secondary endpoints.
Conclusion: This study determined there was insufficient evidence to determine if patients taking chronic oral anticoagulation have the same adverse bleed risk after thrombolytic administration as patients not on anticoagulation.