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Acute anterior-circulation large-vessel occlusion stroke during active apixaban therapy — SCE Geriatric Medici

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HardAcute Medical CareAcute anterior-circulation large-vessel occlusion stroke during active apixaban therapySCE Geriatric Medicine

An 87-year-old man develops sudden left hemiplegia, left visuospatial neglect and dysarthria 90 minutes before assessment. He lived independently with a pre-stroke modified Rankin Scale score of 1. His medical history includes non-valvular atrial fibrillation, for which he takes apixaban 5 mg twice daily; his morning dose was witnessed 3 hours ago. His blood pressure is 178/98 mmHg, capillary glucose is 6.4 mmol/L and NIHSS score is 17. Platelet count is 186 ×10⁹/L, eGFR is 62 mL/min/1.73 m², prothrombin time is 12.8 seconds, INR is 1.1 and activated partial thromboplastin time is normal. An apixaban-calibrated anti-factor Xa assay is not immediately available. Non-contrast CT shows no intracranial haemorrhage and an ASPECTS of 8. CT angiography demonstrates a right M1 middle cerebral artery occlusion. Mechanical thrombectomy is immediately available. Which is the most appropriate reperfusion strategy?

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Correct answer: D — Proceed to mechanical thrombectomy without intravenous thrombolysis or reversal

Explanation lettering: B = shown as A · C = shown as B · D = shown as C · E = shown as D · A = shown as E

This is a disabling acute ischaemic stroke caused by a proximal anterior-circulation large-vessel occlusion, presenting within 6 hours with limited established infarction and good pre-stroke function. NICE therefore supports immediate mechanical thrombectomy. Advanced age does not itself remove eligibility, and treatment should not be delayed. The witnessed apixaban dose 3 hours earlier indicates clinically relevant anticoagulant activity. Normal PT, INR and APTT do not exclude an apixaban effect; a drug-specific anti-factor Xa assay would be required to demonstrate negligible activity. Intravenous alteplase (A) and tenecteplase (B) are therefore inappropriate, although either could precede thrombectomy in an otherwise thrombolysis-eligible patient without effective anticoagulation. Andexanet alfa (C) should not be given merely to facilitate thrombectomy. NICE restricts its recommended use to reversal of apixaban or rivaroxaban in life-threatening or uncontrolled gastrointestinal bleeding; this patient has no bleeding, and reversal would delay reperfusion. Aspirin alone (D) is inadequate because it forfeits an effective disability-reducing intervention for an accessible M1 occlusion. The appropriate strategy is direct thrombectomy without intravenous thrombolysis or factor Xa reversal.

Reference: Stroke and transient ischaemic attack in over 16s: diagnosis and initial management — Recommendations (Published 1 May 2019; last reviewed 27 March 2026) — https://www.nice.org.uk/guidance/NG128/chapter/recommendations Metalyse 5,000 units (25 mg) powder for solution for injection — Summary of Product Characteristics (12 September 2025) — https://www.medicines.org.uk/emc/product/15859/smpc Andexanet alfa for reversing anticoagulation from apixaban or rivaroxaban — Recommendations (Recommendation last updated 15 January 2025; update information April 2026) — https://www.nice.org.uk/guidance/ta697/chapter/1-Recommendations