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Will Symptomatic Intracerebral Hemorrhages Decrease Among Eligible Dabigatran-Treated Patients Who Receive Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke?

Lung Chan, MD, MSc
Arch Neurol. 2010;67(9):1156-1157. doi:10.1001/archneurol.2010.205.
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Current guidelines strongly recommend warfarin for patients with atrial fibrillation and moderate to high risk of stroke, such as those with mitral stenosis or prosthetic heart valve, a history of prior ischemic stroke or systemic embolism, or 2 or more thromboembolic risk factors.1 In the National Institute of Neurological Disorders and Stroke, patients with warfarin treatment are excluded from intravenous tissue plasminogen activator if international normalized ratio (INR) is high (INR > 1.3 in 1995,2 or INR > 1.7 in 20053,4). However, Prabhakaran and colleagues5 revealed a nearly 10-fold higher rate of symptomatic intracranial hemorrhage among patients who were taking warfarin, even with a lower INR (median, 1.04). In the Randomized Evaluation of Long Term Anticoagulant Therapy study,6 dabigatran etexilate demonstrated its effectiveness in prevention of systemic embolism and future stroke with a similar safety profile to warfarin. Will dabigatran-treated patients have a lower risk of symptomatic intracerebral hemorrhage while receiving tissue plasminogen activator treatment for acute ischemic stroke, or should we wait for more evidence?

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