Wake-Up Stroke With M2 Occlusion and Recent Apixaban
74-year-old man with atrial fibrillation was last known well at 23:00 and found at 07:00 with right facial and arm weakness and expressive aphasia. He arrives at 08:10; NIHSS is 9, BP 178/96. Noncontrast CT ASPECTS is 9. CTA shows a left M2 occlusion; CT perfusion shows 15 mL core and 85 mL penumbra (mismatch ratio 5.7). Weight 72 kg; eGFR 32. He takes apixaban 5 mg twice daily, last dose at 22:00. Prestroke mRS is 0, and family confirms he was independent. The stroke team must decide about reperfusion and anticoagulation while the patient is intermittently drowsy.
1. Is intravenous thrombolysis indicated? Explain the factors that drive your decision and what you would tell the family.
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No - IV thrombolysis should not be given here. The main barrier is the apixaban dose 10 hours before presentation. For a DOAC, recent ingestion within 48 hours is generally an exclusion unless reversal has been achieved and coagulation testing supports safe treatment. Apixaban has no routine bedside coagulation assay, and his eGFR of 32 further prolongs drug exposure. Although his BP is below 185/110 and the wake-up time is within a potential thrombolysis window, unknown onset alone would require advanced imaging selection; it does not overcome the anticoagulation issue.
I would tell the family: the clot-dissolving drug carries a meaningful risk of intracranial hemorrhage because of recent apixaban, and we cannot reliably reverse it. The better option is mechanical thrombectomy if imaging supports it. I would not give empiric reversal solely to enable alteplase outside a protocol; andexanet or prothrombin complex concentrate would be considered only for life-threatening bleeding, not routinely to permit thrombolysis.
2. Should he undergo endovascular thrombectomy? Address trial eligibility, M2 location, NIHSS, and imaging selection.
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He is a reasonable candidate for thrombectomy after shared decision-making, but he does not fit the strict DAWN or DEFUSE-3 entry criteria. DAWN generally requires NIHSS ≥10 in the 6–24-hour window; his NIHSS is 9. DEFUSE-3 specified ICA or M1 occlusion, whereas he has an M2 occlusion. Those trial boundaries reflect the populations studied, not a biological prohibition.
His favorable features are a small core (15 mL), large penumbra (85 mL), mismatch ratio 5.7, ASPECTS 9, and prestroke independence. M2 occlusions can cause disabling deficits, and observational data and guideline statements support offering thrombectomy for selected M2 occlusions, especially with a dominant territory deficit and favorable perfusion. The decision should account for operator experience, vessel accessibility, and transfer time. I would offer thrombectomy and explain that evidence is strongest for M1/ICA and less certain for M2, but the mismatch and low core make benefit plausible.
3. If he undergoes successful thrombectomy with TICI 2b reperfusion and no hemorrhagic transformation, when would you restart apixaban and why?
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I would plan early restart, generally within 2–4 days, rather than waiting 1–2 weeks. The infarct is small (15 mL core), reperfusion was successful, and there is no hemorrhagic transformation. Recent randomized data in atrial fibrillation support early DOAC resumption after minor-to-moderate stroke; a delay beyond about 4 days mainly benefits patients with larger infarcts or hemorrhagic transformation, where the bleeding risk is higher.
Before restarting, I would confirm stable neurologic status, repeat imaging if there is unexplained decline, and control BP. I would also address the apixaban dose: 5 mg twice daily is appropriate only if he meets at least two of age ≥80, weight ≤60 kg, or creatinine ≥1.5; otherwise 2.5 mg twice daily may be correct. His eGFR of 32 does not by itself require dose reduction, but renal function and drug interactions should be reviewed.