Intravenous thrombolysis in acute ischemic stroke after reversal of warfarin anticoagulation in patients with mechanical heart valve prostheses and an INR > 1.7

Background Acute ischemic stroke (IS) frequently occurs in patients receiving oral anticoagulant (OAC) therapy. Although warfarin has largely been replaced by direct oral anticoagulants in routine clinical practice, it remains the only approved anticoagulant for certain indications, particularly in patients with mechanical heart valve protstheses. In these patients, the international normalized ratio (INR) is the key determinant of eligibility for intravenous thrombolysis (IVT). We present a potentially effective therapeutic strategy involving rapid reversal of warfarin anticoagulation with four-factor prothrombin complex concentrate (4F-PCC) followed by IVT. Methods We report two patients with similar clinical presentations who were receiving long-term warfarin therapy because of a mechanical aortic valve replacement. 76-year-old man with AIS had complete paralysis of the right lower limb, paresis of the right upper limb, and right central facial palsy. INR was 3.2. The second patient was a 76-year-old woman with dysarthria, left central facial palsy and left-sided hemiparesis. Her admission INR was 1.91. In both patients, CT angiography did not demonstrate arterial occlusion suitable for endovascular therapy. Results In both patients, four-factor prothrombin complex concentrate (4F-PCC) was administered to achieve rapid normalization of the INR. This was immediately followed by standard IVT. Both patients experienced marked neurological improvement, with no hemorrhagic or thromboembolic complications. At the 3-month follow-up, both had achieved complete functional recovery without residual neurological deficits. In conclusion, it can be stated that the chosen procedure led to an excellent clinical outcome in accordance with previously published cases, in the absence of other standard options for recanalization therapy.