[Use of thromboelastography prior to systemic thrombolysis in patients treated with DOACs - case series].

Abstract

The number of patients treated with direct oral anticoagulants (DOACs) is significantly increasing. In acute ischemic stroke, systemic thrombolysis is currently contraindicated for patients who have received DOAC treatment within the last 48 hours. Therefore, it is crucial to assess the continuity of treatment and patient compliance. However,  accurate history is often unavailable. The anticoagulant effect of DOACs can be detected using viscoelastic tests performed by the thromboelastograph (ClotPro®). In our study, we conducted Russell's viper venom (RVV) and Ecarin assay (ECA) tests using a thromboelastograph in 25 patients with acute ischemic stroke who were potentially taking DOACs but were unable to provide an accurate history. Based on the coagulation time, we obtained information regarding the effect of the anticoagulant treatment, and thus compliance, which aided in assessing the eligibility for thrombolysis.  In 11 cases, we observed the ineffectiveness  of the DOAC therapy, 9 of which were later confirmed by heteroanamnesis. These tests enabled thrombolysis in 4 patients. Hemorrhagic complication was observed in one case, which was caused by an underlying, previously undiagnosed chronic lymphocytic leukemia. In the cases we observed, DOAC-specific viscoelastic  tests (RVV, ECA) provided rapid information regarding DOAC administration within the last 48 hours, allowing the identification  of the patients who were eligable for thrombolysis. Overall, these tests assist clinicians in determining compliance,   assessing the possibility of thrombolysis, and reducing the time required to make treatment decisions.