Effect of Heparin Reversal by Protamine Sulfate on the Outcome of Thrombolysis in Acute Ischemic Stroke after Percutaneous Coronary Intervention

Acute ischemic stroke (AIS) after percutaneous cardiac catheterization (PCI) is a known complication with incidence reports of ranges between 0.2% and 0.5%. It is associated with an in-hospital mortality rate of 20%, with markedly increased long-term mortality (1). Administration of Intravenous thrombolysis (IVT) is the recommended standard of care in acute ischemic stroke during the first 4.5 hours from stroke onset. However, current guidelines exclude intravenous thrombolysis in heparinized patients with partial thromboplastin time (PTT) greater than 40 seconds (2) Protamine is an efficient antidote known for the anticoagulant effect of heparin, and it can neutralize its effect within 5 minutes (3).

To assess the safety of IVT after heparin reversal by protamine sulfate in ischemic Stroke patients After PCI.

The total number of patients who developed early IP stroke (within 4.5 hours from the end of PCI) was 42. All of them received loading antiplatelets before PCI.

out of 21 patients received IVT after heparin reversal by protamine, no patient had died, 2 cases had non symptomatic intracranial hemorrhage (ICH), with significant improvement in stroke parameters and shorter length of stay

IVT following heparin reversal by protamine in appropriately selected AIS patients appears to be safe from a symptomatic ICH standpoint and may be beneficial. Extreme caution is warranted in applying these results to routine clinical practice. Rather, we suggest that thrombolysis may still be considered in AIS patients on therapeutic heparin who are not candidates for MT