How are DOACs managed in an acute ischemic stroke with suspected LVO but no hemorrhage?

How are DOACs managed in an acute ischemic stroke with suspected LVO but no hemorrhage?

• A. IV tPA is generally avoided if on DOAC; thrombectomy if LVO; consider delaying anticoagulation until safe per imaging; consult hematology.
• B. Proceed with IV tPA regardless of DOAC.
• C. Continue DOAC and do not perform thrombectomy.
• D. Discontinue DOAC permanently.

Answer: (B)

The main idea here is that restoring blood flow quickly is the priority in an acute ischemic stroke with suspected large vessel occlusion and no hemorrhage. The fastest path to reperfusion is to use mechanical thrombectomy for the occluded vessel, and in eligible patients within the 4.5-hour window, giving intravenous thrombolysis can further boost early reperfusion. Why this answer fits: giving IV tPA promptly within the treatment window aims to initiate clot breakdown right away, which can improve tissue salvage and outcomes, and it complements thrombectomy that will be pursued for definitive occlusion treatment if confirmed. In the absence of hemorrhage on imaging and within the therapeutic window, starting tPA without delay is a priority to maximize chances of recovery, with thrombectomy planned for rapid retrieval of the clot once LVO is identified. If the DOAC history is unclear or reversible factors are involved, hematology consults are useful, but they should not delay urgent reperfusion therapy in this scenario.

The main idea here is that restoring blood flow quickly is the priority in an acute ischemic stroke with suspected large vessel occlusion and no hemorrhage. The fastest path to reperfusion is to use mechanical thrombectomy for the occluded vessel, and in eligible patients within the 4.5-hour window, giving intravenous thrombolysis can further boost early reperfusion.

Why this answer fits: giving IV tPA promptly within the treatment window aims to initiate clot breakdown right away, which can improve tissue salvage and outcomes, and it complements thrombectomy that will be pursued for definitive occlusion treatment if confirmed. In the absence of hemorrhage on imaging and within the therapeutic window, starting tPA without delay is a priority to maximize chances of recovery, with thrombectomy planned for rapid retrieval of the clot once LVO is identified. If the DOAC history is unclear or reversible factors are involved, hematology consults are useful, but they should not delay urgent reperfusion therapy in this scenario.