Patient with a History of DOAC Usage in Neurological ICU with Stroke – Case Study
How should we approach patients with a stroke who are taking direct oral anticoagulants (DOACs) and correctly assess the situation? When should we administer the available antidote according to guidelines? The following case study from the Regional Hospital Liberec illustrates this increasingly common situation.
Clinical Picture
A man, born in 1954, on July 24, 2022, starting in the morning (around 10 o'clock), notices speech disturbance and weakness of the left-sided limbs. At 14:11 he arrives at the emergency department of the Comprehensive Cerebrovascular Center (KCC) at the Regional Hospital Liberec (KNL). At the emergency department, the on-duty neurologist identifies a slight left-sided hemiparesis, dysarthria, central paresis of the facial nerve on the left (n. VII sin), and neglect syndrome. The NIHSS (National Institutes of Health Stroke Scale) score is set at 7. Initial BP 125/89 mmHg.
Anamnesis
The patient is being treated for paroxysmal atrial fibrillation (AF), initially with warfarin, which in 2017 was replaced by dabigatran from the DOACs group in a full dose of 2× 150 mg due to bleeding complications. Additionally, the patient has a history of type 2 diabetes mellitus (DM), hyperlipidemia, and secondary epilepsy due to focal involvement of the central nervous system (CNS). Since the patient does not have an aphasic disorder, he indicates he took all his morning medications.
Diagnostics
After the basic laboratory tests (including CBC, coagulation, and basic biochemistry), the patient is transported for brain imaging. A native CT scan is performed with normal findings. CT angiography (CTAg) of the brain vessels shows no clear stenoses or closures.
Treatment Course
At 14:30, the application of idarucizumab is completed. Approximately 5 minutes later, a control coagulation test is performed, and IVT 80 mg lyophilisate is started, with a bolus administered at 14:37 in the intensive care unit. Subsequently, the initial dabigatran level from the laboratory is 118 ng/ml, with the control level after the administration of idarucizumab being 0 ng/ml.
Discharge
The second day at KNL: NIHSS 2 – dysarthria, slight asymmetry of the mouth corners ad sin. Control CT shows no findings of fresh pathology, with a modified Rankin Scale (mRS) score of 1.
The patient is discharged on July 25, 2022, with minimal deficit.
MUDr. Zuzana Eichlová
Head Physician of the ICU of the Neurocenter, Regional Hospital Liberec
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