Successful intravenous thrombolysis in an acute ischemic stroke patient with contraindicating values of the internationa
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LETTER TO THE EDITOR
Successful intravenous thrombolysis in an acute ischemic stroke patient with contraindicating values of the international standardized ratio and prothrombin time Liming Cao1 · Xibao Tong2 · Hua Lu2 Received: 14 July 2020 / Accepted: 28 September 2020 © The Author(s) 2020
Dear Editor, Warfarin is used abundantly to treat atrial fibrillation and other diseases, because it reduces the relative risk of nonvalvular atrial fibrillation-related stroke by 64% and all-cause mortality by 26% [1]. However, warfarin cannot completely prevent cardiogenic stroke. Recombinant tissue plasminogen activator (rt-PA) is the most effective therapeutic drug for treating acute ischemic stroke (AIS) [2]. However, current guidelines [3, 4] contraindicate the use of intravenous thrombolysis (IVT) when the international standardized ratio (INR) is > 1.7 or the prothrombin time (PT) is > 15 s (level B evidence). IVT with rt-PA in warfarin-treated stroke patients beyond these guidelines is rare. We propose that warfarintreated stroke patients with an INR > 1.7 or PT > 15 s should be individually assessed to determine if IVT is appropriate. Here, we report the case of an AIS patient with INR and PT values beyond the contraindications who underwent IVT and achieved good results. A 53-year-old man was admitted to the emergency department for right limb weakness and speech impediment since 2 h. He had undergone artificial mechanical valve replacement in 2016 for aortic valve severe stenosis with valve regurgitation secondary to rheumatic heart valvular disease. After this, he was prescribed warfarin (3 mg/day). The last dose had been administered 10 h before the onset of symptoms. The patient had no history of cardiovascular risk factors, such as smoking; drinking; hypertension; or diabetes, and * Liming Cao caolm‑[email protected] 1
Department of Neurology, The Third Affiliated Hospital of Shenzhen University, 47 Friendship Road, Luohu District, Shenzhen 518000, China
Department of Internal Medicine, People’s Hospital of Xilin County, Baise 533500, Guangxi, China
2
infectious or genetic diseases. Physical examination showed blood pressure of 119/70 mmHg, somnolence, motor aphasia, right central facial paralysis, decreased muscle strength in right upper and lower limbs (4/5), positive right Babinski sign, and normal cardiac rhythm. His National Institutes of Health Stroke Scale (NIHSS) score was 6. Emergency computed tomography (CT) showed no obvious abnormalities (Fig. 1a, b). Blood coagulation test showed raised INR (2.18) and PT (25.63 s) (Table 1). Platelet count, blood electrolyte levels, random blood sugar levels, and electrocardiography findings were all normal. The patient was informed of the potential risks and benefits of IVT, and he provided consent for the procedure. IVT with rt-PA (0.8 mg/kg) was administered 3 h after the onset of symptoms, with an initial 0.9 mg/kg intravenous bolus injection, representing 10% of the total dosage. The remainder was administered intravenously over 1 h. We administered an
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