Intravenous thrombolysis in a patient using factor Xa inhibitor

Until recently, only warfarin was approved for the prevention of stroke in patients with AF. Patients on warfarin with ischemic stroke were considered candidates for IV tPA as long as their PT/INR was not prolonged. Now, there are several new agents approved for stroke prevention in patients with non-valvular AF. The newer agents include direct thrombin inhibitors, like dabigatran, and factor Xa inhibitors, like rivaroxaban and apixaban. The coagulation profile of patients on direct thrombin inhibitors is more predictable than that of patients on factor Xa inhibitors, and the usage of IV tPA in patients on dabigatran has been previously reported. To our knowledge, there are no prior reports of IV tPA in a patient on a factor Xa inhibitor. We report a case of a 71-year-old man on rivaroxaban who improved with IV tPA after presenting with acute onset of aphasia and right-sided weakness