Use of intravenous recombinant tissue plasminogen activator in patients with borderline elevation of international normalized ratio

Abstract

Objective: To determine the rates of symptomatic intracerebral hemorrhages (sICH), parenchymal hematoma type 2 (PH2), and favorable outcomes in patients with borderline elevation of international normalized ratio (INR) or recent anticoagulation use prior to treatment with intravenous recombinant tissue plasminogen activator (IV rt-PA) for acute ischemic stroke.
Methods: Consecutive patients with acute ischemic stroke that received IV rt-PA were identified. History
of recent use of anticoagulation and the INR at presentation and after use of thrombolytics, up to 72 h was
recorded. Neuroimaging and clinical charts were reviewed for evidence of sICH. Outcomes were recorded
at the time of discharge and on follow-up up to 6 months using the modified Rankin scale (mRS).
Results: A total of 106 patients (mean age was 65.95 ± 15.29 years and 55.67% were men) were identified. Of these, 12 (11.3%) patients had initial INR elevation (1.2–1.7) and 12 (11.3%) patients that had
recently received oral anticoagulation. The rate of PH2 was higher in patients on anticoagulation or with
elevated initial INR compared to patients with normal INR and no history of anticoagulation (15.79% versus 2.30%, P = 0.023). In subgroup analyses, elevation of INR during the first 24 h and history of recent
use of anticoagulation in a different analysis inversely correlated with favorable outcomes at discharge and
at follow-up.
Conclusion: Borderline elevation in INR or recent use of anticoagulation before thrombolytic use can
increase the rate of ICH in patients treated with IV rt-PA for acute ischemic stroke. These patients should
cautiously receive thrombolytics for acute ischemic stroke as per the AHA/ASA Stroke Council guidelines.