RESUMO
RATIONALE: Whether intravenous recombinant tissue plasminogen activator (r-TPA) therapy can be administered in acute ischemic stroke patients treated with novel oral anticoagulants (NOACs), including rivaroxaban, remains controversial. PATIENT CONCERNS: A 76-year-old woman with nonvalvular atrial fibrillation, who had been receiving 15âmg rivaroxaban once daily, was brought to the emergency department with right-side hemiparesis and aphasia. The onset of neurological deficits occurred 8âhours after the last dose of rivaroxaban administration. DIAGNOSIS: The patient was diagnosed with acute ischemic stroke. INTERVENTIONS: Intravenous infusion of 0.6âmg/kg of r-TPA (total dose: 29âmg) was performed 9âhours and 40âminutes after the last rivaroxaban administration. During r-TPA infusion, improvement in the patient's neurological deficit was observed. OUTCOMES: The clinical picture evidently improved from with National Institutes of Health Stroke Scale 21 to 16 on completion of r-TPA treatment. LESSONS: Although current guidelines do not recommend administering thrombolytics in patients using NOACs with a doubtful anticoagulation status and administered within the last 24 or, even more strictly, 48âhours, this and other case studies suggest that r-TPA treatment could be considered in selected acute ischemic stroke patients receiving rivaroxaban or other Xa inhibitors, taking the patient's clinical condition and the prospective clinical benefits of r-TPA into account.