Endovascular treatment in acute ischemic stroke patient on factor Xa inhibitor

Warfarin has primarily been used for prevention of ischemic stroke in patients with atrial fibrillation for nearly 30 years [1]. More recent studies and trials have demonstrated the efficacy of new oral anticoagulants (NOACs) such as direct thrombin inhibitors and factor Xa inhibitors as a source of alternative therapy in preventing ischemic strokes in patients with atrial fibrillation. These NOACs also have the added benefit of minimizing labor intense methods such as the routine coagulation parameter monitoring that is often done in the case of warfarin. Therapeutic efficacy was elucidated by the ROCKET-AF trial which demonstrated noninferiority of rivaroxaban, a factor Xa inhibitor, to warfarin in prevention of stroke and systemic embolism [2]. However, treatment of patients who experience an acute ischemic stroke despite being on the aforementioned NOACs such as rivaroxaban has not been documented. The only FDA approved treatment for acute stroke with class I recommendation and holding level A evidence is intravenous recombinant tissue plasminogen activator (IV tPA) [3]. Even patients on warfarin who suffer from an ischemic stroke may be treated with IV tPA provided that the international normalized ratio (INR) and platelet thromboplastin time (PTT) are not elevated [4]. However, owing to the relatively newer profiles of the various NOACs, there are currently no readily available assays in existence to determine their level of anticoagulation in a NOAC user. Inability to determine the state of anticoagulation in turn makes decision to provide treatment with IV tPA difficult in such patients who suffer from ischemic strokes. Several other articles have been published describing the incidence of complications and recommended discontinuing direct thrombin inhibitors preprocedural [5,6]. To counter such dilemma, intra-arterial tPA (IA tPA) proves to be a viable therapeutic option when the administration of IV tPA is contraindicated [5]. The safety profile of IA tPA for clot dissolution is further strengthened owing to the smaller amount of the total dosage that is ultimately required for clot delivery. In fact, the efficacy of IA tPA application in patients with elevated INR secondary to warfarin use has been reported [7,8]. However, to our knowledge, there are no prior reports of administering IA tPA and mechanical thrombectomy in a patient who is on a factor Xa inhibitor. We report a case of a 79-year-old man on rivaroxaban who presented with acute onset of right gaze deviation and left-sided weakness, and showed clinical improvement with IA tPA