Should I hold Eliquis (apixaban) for a cerebrovascular accident (CVA) rule out admission pending a magnetic resonance imaging (MRI)?

Management of Eliquis During CVA Rule Out Pending MRI

Eliquis (apixaban) should be temporarily held when a patient is admitted for cerebrovascular accident (CVA) rule out pending MRI, particularly if there is concern for hemorrhagic stroke. This approach prioritizes patient safety by reducing the risk of hemorrhagic complications while diagnostic evaluation is completed.

Rationale for Holding Anticoagulation

When a patient presents with symptoms concerning for stroke, it is crucial to determine whether the event is ischemic or hemorrhagic before continuing anticoagulation:

• Non-contrast head CT is the gold standard initial test to rule out hemorrhage (rated 9/9 for appropriateness) 1
• MRI is more sensitive for detecting acute infarcts and can help determine the age of infarction 1
• Continuing anticoagulation in the setting of hemorrhagic stroke could significantly worsen outcomes

Timing Considerations

The decision to hold Eliquis should follow this algorithm:

1. Initial presentation: Hold Eliquis immediately upon admission for CVA rule out
2. After initial non-contrast CT:
   • If hemorrhage is detected: Continue to hold Eliquis indefinitely
   • If no hemorrhage is detected: Continue to hold Eliquis pending MRI results
3. After MRI completion:
   • If ischemic stroke confirmed: Decision to restart depends on stroke size, risk of hemorrhagic transformation, and time since symptom onset
   • If hemorrhagic stroke confirmed: Continue to hold Eliquis

Specific Timing for Restarting Anticoagulation

For patients with confirmed ischemic stroke:

• For small to moderate ischemic strokes: Typically safe to restart anticoagulation after 3-14 days
• For large ischemic strokes: May need to wait 2-4 weeks due to higher risk of hemorrhagic transformation

For patients with hemorrhagic stroke:

• Anticoagulation is generally contraindicated, especially in patients with cerebral amyloid angiopathy 2
• The American Heart Association/American Stroke Association recommends avoiding oral anticoagulants due to prohibitively high bleeding risk in patients with cerebral amyloid angiopathy 2

Special Considerations

Risk of Spinal/Epidural Hematoma

If lumbar puncture is planned as part of the workup:

• Eliquis should be discontinued at least 48 hours prior to procedures with moderate or high risk of bleeding 3
• For low bleeding risk procedures, discontinue at least 24 hours prior 3

Monitoring During Anticoagulation Interruption

While Eliquis is held:

• Monitor neurological status frequently (at minimum every 4 hours in non-ICU setting) 1
• Maintain blood pressure control to reduce risk of hemorrhagic transformation
• Consider bridging anticoagulation only for patients at very high thrombotic risk (mechanical heart valves)

Resuming Anticoagulation

When restarting Eliquis after ruling out hemorrhage:

• Ensure adequate hemostasis has been established 3
• For patients with atrial fibrillation who had an ischemic stroke, restart when considered safe from the perspective of hemorrhagic transformation, typically between 2 and 14 days following an acute event 1
• For patients with confirmed TIA (no infarct or hemorrhage on imaging), anticoagulation can typically be initiated immediately 1

Common Pitfalls to Avoid

1. Restarting anticoagulation too early after ischemic stroke, increasing risk of hemorrhagic transformation
2. Delaying anticoagulation unnecessarily in patients with high thrombotic risk
3. Failing to consider alternative stroke prevention strategies in patients with contraindications to anticoagulation
4. Not recognizing cerebral amyloid angiopathy as a contraindication to anticoagulation

In summary, temporarily holding Eliquis during CVA rule out pending MRI is the safest approach to prevent potential hemorrhagic complications while determining the appropriate long-term management strategy.