Wake-Up Stroke With a Large Vessel Occlusion on a Direct Oral Anticoagulant
A 72-year-old woman with atrial fibrillation on apixaban 5 mg twice daily (last dose 22:00) was last seen well at 21:30 the previous evening. She was found at 06:30 with dense right hemiparesis, global aphasia, and gaze deviation. NIHSS is 15. Noncontrast CT shows ASPECTS 8 with subtle caudate and insular hypodensity; CTA shows a left M1 occlusion. CT perfusion: ischemic core (rCBF <30%) 28 mL, Tmax >6 s volume 95 mL. Weight 70 kg, creatinine 1.1 mg/dL, platelets 210,000, glucose 128 mg/dL, BP 168/92. Groin access is available and door-to-imaging time was 22 minutes. Her daughter, who holds medical power of attorney, asks whether "it is too late for the clot retrieval" and whether the blood thinner changes anything.
1. Should this patient undergo endovascular thrombectomy? Justify your answer using the enrollment logic of the late-window trials rather than a general recommendation.
Read the worked answer
Yes - she meets late-window criteria on imaging grounds, not clock grounds.
- Time: last known well ~9 h, but this is a wake-up stroke; the true onset is unknown and imaging, not the clock, adjudicates candidacy.
- DAWN logic (clinical-core mismatch): age <80, NIHSS ≥10, core <31 mL. She has NIHSS 15 and a 28 mL core - she fits.
- DEFUSE-3 logic (perfusion mismatch): core <70 mL AND mismatch ratio >1.8 AND penumbra >15 mL. Core 28 mL, Tmax volume 95 mL, ratio 3.4 - she fits comfortably.
- ASPECTS 8 does not exclude her. It is not a trial exclusion; it predicts a smaller chance of functional independence, not futility, and should be part of the conversation, not the decision.
- Apixaban is not a contraindication. DOAC therapy blocks thrombolysis, not mechanical retrieval. There is no INR or anticoagulation washout requirement for thrombectomy, and the added sICH risk from the procedure itself is small.
The correct judgment is to proceed immediately and to have the risk conversation in parallel, not before transfer to the angio suite. Door-to-groin time is the only modifiable variable left.
2. She is successfully recanalized (TICI 2b) and arrives in the ICU. What blood pressure target do you set for the next 24 hours, and what is the reasoning behind not simply driving her pressure 'lower'?
Read the worked answer
Target: keep SBP roughly 140-180 mmHg (avoid >180/105 and avoid <130 SBP), then re-evaluate after 24 h.
Reasoning:
- Guideline floor and ceiling. Peri- and post-procedural guidance is <180/105 mmHg; below that, the evidence for further lowering after successful reperfusion is not supportive.
- The brain is at risk of both hypertension and hypotension. With a 28 mL core and a reperfused M1 territory, cerebral autoregulation is impaired. Perfusion in the salvaged penumbra becomes pressure-passive; a MAP drop can convert viable tissue into infarct.
- Randomized data show harm from intensive lowering. Trials of intensive targets (SBP <120-140) after thrombectomy showed worse functional outcomes and more early neurologic deterioration than standard targets.
- Practical execution. Continue the arterial line; avoid deep sedation that drops MAP; treat SBP >180 with a titratable agent (labetalol, nicardipine) rather than a bolus that overshoots; document the target in the order set so night coverage does not chase a 'normal' pressure.
If she fails to reperfuse (TICI 0-1), permissive hypertension up to 180/105 is standard, since there is no hemorrhagic risk from reperfusion and the penumbra may depend on collateral pressure.
3. When do you restart her anticoagulation, and what must you document before doing so?
Read the worked answer
Plan: repeat CT/MRI at 24 h, exclude hemorrhagic transformation and significant infarct swelling, then restart apixaban around day 3-5 (not immediately, not in 2 weeks).
Decision framework:
- The competing risks. Early restart reduces recurrent cardioembolism (her stroke occurred on appropriate dosing, so the recurrence risk is real); late restart reduces parenchymal hematoma, which is most likely in the first 48-72 h and is amplified by reperfusion and a 28 mL core.
- Size and reperfusion drive timing. Small infarcts can be restarted at ~2-3 days; a moderate core with successful TICI 2b reperfusion - her case - lands at roughly 3-5 days; large territorial infarcts (>1/3 MCA) with hemorrhagic transformation warrant 1-2 weeks. Re-image at 24 h; if any petechial hemorrhage is present, wait and re-image again.
- No bridging. Low-molecular-weight heparin bridging is not recommended; it raises hemorrhagic risk without proven benefit.
- Anti-platelet question. She does not need dual therapy; single anti-platelet therapy is reasonable in the interim if there is a concern about stent placement, otherwise her long-term prevention is the DOAC.
- Document: the exact time of the last CT, the absence of hemorrhage, the bleed-versus-recurrence rationale, and the plan for neurologic checks and a repeat scan if she deteriorates.