Thrombolysis for ischaemic stroke despite direct oral anticoagulation

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  Figure 1. Algorithm for intravenous off-label thrombolysis in patients with acute ischaemic stroke on treatment with direct oral anticoagulants (DOACs). *Optional: administration of idarucizumab (two times 2.5 g intravenously before IVT) if available immediately. ‡Restrict IVT to patients in early time window (rationale: median time to IVT was 2.5 hours (1.8–3.5) in Meinel et al; MRI might help to determine patients eligible for IVT in wake-up stroke or unknown time windows (DWI/FLAIR mismatch)). Factor Xa inhibitors=apixaban, edoxaban, rivaroxaban. A2, segment of the anterior cerebral artery; BA, basilar artery; DWI, diffusion-weighted imaging; FLAIR, fluid-attenuated inversion recovery; ICA, internal carotid artery; IVT, intravenous thrombolysis; LVO, large vessel occlusion; M1, M2, segments of the middle cerebral artery; MT, mechanical thrombectomy; P2, segment of the posterior cerebral artery; sICH, symptomatic intracranial haemorrhage.