When can anticoagulants be restarted post Tenecteplase (tnk) administration for acute ischemic stroke?

Restarting Anticoagulants After Tenecteplase (TNK) Administration

Anticoagulants should be discontinued during the acute period for at least 1-2 weeks after tenecteplase administration for acute ischemic stroke, and can typically be safely restarted at approximately 3-4 weeks after bleeding risk has been assessed and stabilized. 1

Initial Management After TNK Administration

• Immediately discontinue all anticoagulants and antiplatelets during the acute period following TNK administration 2
• Monitor closely for any signs of hemorrhagic transformation in the first 24-48 hours
• For patients who received TNK for acute ischemic stroke, maintain blood pressure <180/105 mmHg for at least the first 24 hours 2

Risk Assessment Before Restarting Anticoagulation

Before considering restarting anticoagulation, evaluate:

1. Bleeding risk factors:

   • Presence of hemorrhagic transformation on follow-up imaging
   • Size of infarct
   • Blood pressure control
   • Age and other comorbidities

2. Thrombotic risk factors:

   • Indication for anticoagulation (e.g., atrial fibrillation, mechanical heart valve)
   • History of previous thromboembolism
   • CHADS2-VASc score for AF patients

Timing for Restarting Anticoagulation

The decision to restart anticoagulation should be based on balancing the risk of thromboembolism against the risk of hemorrhagic transformation:

• High thrombotic risk patients (mechanical heart valves, recent venous thromboembolism):

  • Consider restarting at 7-10 days if follow-up imaging shows no hemorrhagic transformation 2

• Moderate thrombotic risk patients (atrial fibrillation with prior stroke):

  • Typically safe to restart at 3-4 weeks after TNK administration 1

• Lower thrombotic risk patients (atrial fibrillation without prior stroke):

  • May consider delaying anticoagulation for 4 weeks or longer 2

Follow-up Imaging Recommendations

• Obtain follow-up brain imaging at 24 hours post-TNK to assess for hemorrhagic transformation
• Consider additional imaging at 7-10 days before making decision to restart anticoagulation
• For patients with any evidence of hemorrhagic transformation, repeat imaging to confirm stability before restarting anticoagulation

Special Considerations

• For patients on direct oral anticoagulants (DOACs) prior to stroke, consider switching to a DOAC when restarting anticoagulation due to potentially lower risk of intracranial hemorrhage compared to warfarin 1
• If using warfarin, consider maintaining INR in the lower end of the therapeutic range initially 1
• Consider bridging therapy with prophylactic-dose low molecular weight heparin in high-risk patients after the first week if clinically indicated

Monitoring After Restarting Anticoagulation

• Close clinical monitoring for the first 2-4 weeks after restarting anticoagulation
• Educate patients about warning signs requiring immediate medical attention (new-onset severe headache, confusion, decreased level of consciousness)
• Consider follow-up imaging 2-4 weeks after restarting therapy to assess for any new bleeding 1

The evidence for optimal timing of anticoagulation after TNK is limited, but the general principles follow those for post-stroke anticoagulation, with careful consideration of the increased bleeding risk associated with thrombolytic therapy.