Skip to main content

Feasibility of IA Thrombolysis for Acute Ischemic Stroke Among Anticoagulated Patients


Background and purpose

Limited information exists regarding thrombolysis among anticoagulated acute stroke patients. We present data from three consecutive patients, on active warfarin therapy, treated with intra-arterial reteplase.


All patients were screened for the presence of intracranial hemorrhage. Warfarin was reversed with fresh frozen plasma in all patients and cerebral angiography and intra-arterial administration of reteplase was performed. Computed tomographic scans were performed to detect any subsequent intracranial hemorrhage. Ages ranged from 58 to 79 years with initial National Institutes of Health Stroke Scale scores ranging from 12 to 17. Baseline international normalized ratios (INRs) were 1.99–2.25. None of the patients suffered from intracranial hemorrhage following thrombolysis, and two of the patients experienced early neurological improvement.


Low dose, intra-arterial reteplase following acute reversal of elevated INR is feasible and may offer a potential treatment for patients suffering with acute ischemic stroke while receiving active warfarin treatment.

This is a preview of subscription content, access via your institution.


  1. The National Institutes of Neurological Disorders, Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. NEJM 1995;333:1581–7.

    Google Scholar 

  2. Adams HP, Brott TG, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Kwiatkowski T, Lyden PD, Marler JR, Torner J, Feinberg W, Mayberg M, Thies W. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for themanagmenet of patients with acute ishcemic stroke. Circulation 1996;94:1167–74.

    PubMed  Google Scholar 

  3. Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, Pessin M, Ahuja A, Callahan F, Clark WM, Silver F, Rivera F. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. JAMA 1999;282:2003–11.

    PubMed  Article  CAS  Google Scholar 

  4. del Zoppo GJ, Higashida RT, Furlan AJ, Pessin MS, Rowley HA, Gent M. PROACT: a phase II randomized trial of recombinant pro-urokinase by direct arterial delivery in acute middle cerebral artery stroke. PROACT Investigators. Prolyse in Acute Cerebral Thromboembolism. Stroke 1998;29:4–11.

    PubMed  Google Scholar 

  5. Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989;20864–70.

  6. Kase CS, Furlan AJ, Wechsler LR, Higashida RT, Rowley HA, Hart RG, Molinari GF, Frederick LS, Roberts HC, Gebel JM, Sila CA, Schulz GA, Roberts RS, Gent M. Cerebral hemorrhage after intra-arterial thrombolysis for ischemic stroke: the PROACT II trial. Neurology 2001;57:1603–10.

    PubMed  CAS  Google Scholar 

  7. Larrue V, von Kummer R, Muller A, et al. Risk factors for severe hemorrhagic transformation in ischemic stroke patients treated with recombinant tissue plasminogen activator: a secondary analysis of the European-Australasian Acute Stroke Study (ECASS II). Stroke. 2001; 32:3438–41.

    Google Scholar 

  8. 1998, 2001 ACCP Recommendations for Reversing Excessive Warfarin-Associated AC adapted from Wilson SE, Douketis JD, Crowther MA. Treatment of warfarin-associated coagulopathy: a physician survey. Chest 2001;120:1972–6.

    Google Scholar 

  9. Fugate SE, Nichols CM, Cudd LA. Impaired warfarin response secondary to high-dose vitamin K1 for rapid anticoagulation reversal: case series and literature review. Pharmacotherapy 2004;24:1213–20.

    PubMed  Article  Google Scholar 

  10. Patiroglu T, Karakukcu M. Middle cerebral arterial thrombosis in a patient with hypofibrinogenemia, 5 days after rFVIIa and FFP infusion. Clin Appl Thromb Hemost 2006;12:111–3.

    PubMed  Article  Google Scholar 

  11. Mielke O, Wardlaw J, Liu M. Thrombolysis (different doses, routes of administration and agents) for acute ischaemic stroke. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD000514.

Download references


The authors have no additional acknowledgements or financial disclosures to state. This article does include discussion of the off-label use of intra-arterial reteplase for stroke treatment.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Nazli Janjua.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Janjua, N., Alkawi, A., Georgiadis, A. et al. Feasibility of IA Thrombolysis for Acute Ischemic Stroke Among Anticoagulated Patients. Neurocrit Care 7, 152–155 (2007).

Download citation

  • Published:

  • Issue Date:

  • DOI:


  • Thrombolysis
  • Intraarterial
  • Stroke
  • Acute ischemic
  • Coagulopathy
  • Warfarin