Wake-Up Stroke on Apixaban: The Family Asks for Clot-Busting

Time window: last known well is 22:00; arrival is 07:10, roughly 9 hours later. Even if the stroke occurred at 06:30, the only defensible clock is the last time he was seen normal. Intravenous thrombolysis is licensed within 4.5 hours of last known well, so he is outside that window on time alone. This is a wake-up stroke and must be treated as unknown onset.

Anticoagulation: apixaban 5 mg taken at 21:00 means a direct oral anticoagulant within roughly 10 hours. Current guidance for thrombolysis excludes patients on a direct oral anticoagulant unless coagulation testing (anti-Xa activity, or a normal-specific assay) confirms no clinically relevant drug effect, and the last dose timing usually must be beyond 48 hours. INR is not the right test for apixaban and a normal INR does not exclude drug effect. So thrombolysis is also contraindicated on this ground.

What remains possible: mechanical thrombectomy. Randomised trials support endovascular treatment up to 24 hours in selected patients with large vessel occlusion and salvageable tissue on perfusion imaging or a diffusion-weighted imaging/fluid-attenuated inversion recovery mismatch. Anticoagulation is not a contraindication to thrombectomy, and the CT angiography suite is free. The reasoning is that the question is not 'can we give the drug' but 'can we open the vessel' - and the answer to the second is still open until imaging says otherwise.

Blood pressure: 192/104 mmHg. Because thrombolysis is not planned, there is no need to force the pressure down to below 185/110. In acute ischaemic stroke, permissive hypertension preserves penumbral perfusion; treatment is generally reserved for pressures above 220/120 mmHg, or lower thresholds when there is another compelling indication such as aortic dissection, acute coronary syndrome, or hypertensive encephalopathy, and then the reduction should be cautious (about 10–15% in the first hours). Aggressive lowering here could extend the infarct.

What not to do

• Do not give aspirin or any antiplatelet within 24 hours, and certainly not while he is anticoagulated - this needs an explicit stroke team decision.
• Do not give anything by mouth, including medications, until a swallow screen is completed; he has dysarthria and a facial component.
• Do not delay transfer for repeat imaging or for a formal coagulation result if the thrombectomy centre will accept him.

What to do

• Two large-bore cannulae, continuous cardiac monitoring, 12-lead ECG (the irregular pulse suggests atrial fibrillation - establish whether it is known), oxygen only if SpO2 <94%, glucose treated towards 8–10 mmol/L, nil by mouth, head of bed flat or up to 30 degrees as tolerated, avoid urinary catheter unless necessary.
• Document the exact last-known-well time with its source, the last apixaban dose, weight, and a repeat National Institutes of Health Stroke Scale.
• Keep the family informed and prepare transfer documentation and imaging on a disc or network link.

Counselling, honestly and without false hope or false closure: 'The clot-busting drug is not safe for your father. The stroke started while he was asleep, so we cannot be certain it began within the window the drug requires, and he took apixaban last night, which makes bleeding in the brain far too likely. There is another treatment - a procedure to pull the clot out of a large artery - that can still be done many hours after symptoms start in the right patients. That depends on the scan, and time matters, so we are moving quickly.' Avoid quoting survival or recovery percentages; the stroke team should give the prognostic discussion.

Consent and decision-making: ask the son directly whether his father has a health care power of attorney or advance directive, and whether he is the nominated decision-maker - do not assume that the accompanying relative holds authority. In a time-critical emergency with an incapacitated adult, clinicians may treat under the doctrine of necessity, and thrombectomy consent is generally taken by the stroke or interventional team, not by the emergency nurse.

Safest disposition: discuss with the stroke team or on-call neurology now. If CT angiography shows a large vessel occlusion, transfer to the thrombectomy centre immediately - the 45-minute transfer is a reason to move, not to hesitate. If no large vessel occlusion is found, admit locally to a stroke unit for monitoring, swallow assessment, secondary prevention review including the apixaban and possible atrial fibrillation, and early therapy referral. Document the last-known-well source and every conversation with the family.