Reversal of Vitamin K Antagonist Therapy by Prothrombin Complex Concentrate before Thrombolysis for Acute Stroke

Vitamin K antagonist (VKA) frequently fails to prevent cerebral infarction, with 30% of VKA-treated patients experiencing ischemic stroke despite an international normalized ratio (INR) of ≥ 2 [1] . Intravenous (IV) thrombolysis is only recommended for patients with an INR of 1.7. The mean ± SD values of the 4 patients included to date are the following: age 82 ± 1.3 years, National Institute of Health Stroke Scale (NIHSS) score of 14 ± 2.7, initial INR of 2.1 (range: 1.8–2.4), and stroke onset-to-needle time of 187 ± 23 min. The mean post-reversal INR declined to 1.23 (range: 1.2–1.3), and no thrombotic complications occurred. The mean 24-hour NIHSS score was 6.5 ± 3.8. Of the 4 included patients, 3 were fully recanalized on 24-hour control magnetic resonance imaging, and 1 had an asymptomatic thrombolysisrelated type 1 intracerebral hemorrhage. These preliminary observations are very encouraging. The real therapeutic challenge might be not only extending IV thrombolysis to ischemic stroke patients on VKA, regardless of their INR value, but also using a similar strategy in patients receiving new oral anticoagulants if effective antidotes become available.