Successful Intravenous Thrombolysis and Endovascular Treatment for Acute Ischemic Stroke in a Patient Pretreated with Ticagrelor: A Case Report and Literature Review

Abstract

Ticagrelor is a direct-acting antiplatelet agent that reversibly inhibits the P2Y12 receptor on platelets [1]. It is widely used in the setting of coronary acute syndromes [2], but is also a drug of interest in the cerebrovascular field. Indeed, a recent trial showed the efficacy of ticagrelor and acetylsalicylic acid (aspirin) for secondary prevention in acute ischemic stroke patients (AIS) [3]. According to international guidelines, intravenous thrombolysis (IVT) should be administered for AIS treatment regardless of single or dual antiplatelet therapy (DAPT) pretreatment [4]. Literature on IVT in patients pretreated with ticagrelor is limited to a few case reports [5–8]. The increased use of ticagrelor, in both the cardiovascular and the cerebrovascular fields, will likely reflect in more patients pretreated with ticagrelor admitted with AIS and otherwise eligible for IVT. We present a case of a patient pretreated with ticagrelor who underwent bridge therapy for AIS treatment. In January 2021, an 80-year-old male patient was hospitalized for ST-segment elevation myocardial infarction (STEMI). Pretreatment with aspirin 300 mg and ticagrelor 180 mg loading dose followed by primary percutaneous transluminal coronary angioplasty on the left anterior descending artery was performed. Post-interventional therapy with aspirin 100 mg once a day (OD) and ticagrelor 90 mg twice daily (BID) was established. Four days later the patient suddenly experienced left hemiparesis and slurred speech. A computed tomography (CT) scan excluded intracerebral hemorrhage (ICH) and early ischemic changes (Alberta Stroke Program Early CT Score (ASPECTS) was 10) (Fig. 1), while CT angiography showed occlusion at the M1 segment of the right middle cerebral artery. The baseline National Institutes of Health Stroke Scale (NIHSS) score was 4. Intravenous alteplase 0.9 mg/kg was started in a primary stroke center (onset-to-treatment time 230 min) and the patient was transferred to our Comprehensive Stroke Center for endovascular treatment (EVT). Complete recanalization (thrombolysis in cerebral infarction (TICI) score 3) was achieved with first-pass direct thromboaspiration (Fig. 1S, Online Supplementary Material). A 24-h CT scan showed a small right fronto-insular ischemic lesion with no hemorrhagic transformation (Fig. 1) and treatment with ticagrelor 90 mg BID and aspirin 100 mg OD was restarted. Only mild dysarthria persisted at discharge (NIHSS score 1) and the 3-month modified Ranking Score (mRS) was 1. To our knowledge, this is the first case of bridge therapy with alteplase and thromboaspiration for anterior circulation large vessel occlusion AIS in a patient pretreated with ticagrelor, with excellent functional outcome (mRS1) and without hemorrhagic transformation. To date, only seven cases of IVT in ticagrelor pretreated patients have been described in the literature [5–8] (Table 1). All patients were on ticagrelor treatment for cardiovascular reasons, except one who was treated for severe intracranial atherosclerotic disease not responding to clopidogrel. Hemorrhagic complications were reported in four cases: two symptomatic ICH (sICH), one asymptomatic ICH, and a retropharyngeal hematoma. The three patients without hemorrhagic complications suffered from posterior circulation ischemic stroke; alteplase at standard dose was used in two cases and tenecteplase 0.25 mg/kg was administered in the other one. Two patients presented large vessel occlusion AIS but only one underwent EVT with poor clinical outcome for non-intracranial hemorrhagic complication despite successful recanalization. * Federica Rizzo [email protected]; [email protected]