Bridging thrombolysis in atrial fibrillation stroke is associated with increased hemorrhagic complications without improved outcomes.
stroke
thrombectomy
thrombolysis
Journal
Journal of neurointerventional surgery
ISSN: 1759-8486
Titre abrégé: J Neurointerv Surg
Pays: England
ID NLM: 101517079
Informations de publication
Date de publication:
Oct 2022
Oct 2022
Historique:
received:
06
07
2021
accepted:
27
09
2021
pubmed:
26
11
2021
medline:
17
9
2022
entrez:
25
11
2021
Statut:
ppublish
Résumé
Atrial fibrillation (AF) associated ischemic stroke is associated with worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Conversely, AF is not associated with hemorrhagic complications or functional outcomes in patients undergoing mechanical thrombectomy (MT). This differential effect of MT and IVT in AF associated stroke raises the question of whether bridging thrombolysis increases hemorrhagic complications in AF patients undergoing MT. This international cohort study of 22 comprehensive stroke centers analyzed patients with large vessel occlusion (LVO) undergoing MT between June 1, 2015 and December 31, 2020. Patients were divided into four groups based on comorbid AF and IVT exposure. Baseline patient characteristics, complications, and outcomes were reported and compared. 6461 patients underwent MT for LVO. 2311 (35.8%) patients had comorbid AF. In non-AF patients, bridging therapy improved the odds of good 90 day functional outcomes (adjusted OR (aOR) 1.29, 95% CI 1.03 to 1.60, p=0.025) and did not increase hemorrhagic complications. In AF patients, bridging therapy led to significant increases in symptomatic intracranial hemorrhage and parenchymal hematoma type 2 (aOR 1.66, 1.07 to 2.57, p=0.024) without any benefit in 90 day functional outcomes. Similar findings were noted in a separate propensity score analysis. In this large thrombectomy registry, AF patients exposed to IVT before MT had increased hemorrhagic complications without improved functional outcomes, in contrast with non-AF patients. Prospective trials are warranted to assess whether AF patients represent a subgroup of LVO patients who may benefit from a direct to thrombectomy approach at thrombectomy capable centers.
Sections du résumé
BACKGROUND
BACKGROUND
Atrial fibrillation (AF) associated ischemic stroke is associated with worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Conversely, AF is not associated with hemorrhagic complications or functional outcomes in patients undergoing mechanical thrombectomy (MT). This differential effect of MT and IVT in AF associated stroke raises the question of whether bridging thrombolysis increases hemorrhagic complications in AF patients undergoing MT.
METHODS
METHODS
This international cohort study of 22 comprehensive stroke centers analyzed patients with large vessel occlusion (LVO) undergoing MT between June 1, 2015 and December 31, 2020. Patients were divided into four groups based on comorbid AF and IVT exposure. Baseline patient characteristics, complications, and outcomes were reported and compared.
RESULTS
RESULTS
6461 patients underwent MT for LVO. 2311 (35.8%) patients had comorbid AF. In non-AF patients, bridging therapy improved the odds of good 90 day functional outcomes (adjusted OR (aOR) 1.29, 95% CI 1.03 to 1.60, p=0.025) and did not increase hemorrhagic complications. In AF patients, bridging therapy led to significant increases in symptomatic intracranial hemorrhage and parenchymal hematoma type 2 (aOR 1.66, 1.07 to 2.57, p=0.024) without any benefit in 90 day functional outcomes. Similar findings were noted in a separate propensity score analysis.
CONCLUSION
CONCLUSIONS
In this large thrombectomy registry, AF patients exposed to IVT before MT had increased hemorrhagic complications without improved functional outcomes, in contrast with non-AF patients. Prospective trials are warranted to assess whether AF patients represent a subgroup of LVO patients who may benefit from a direct to thrombectomy approach at thrombectomy capable centers.
Identifiants
pubmed: 34819345
pii: neurintsurg-2021-017954
doi: 10.1136/neurintsurg-2021-017954
doi:
Substances chimiques
Fibrinolytic Agents
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
979-984Investigateurs
Sébastien Richard
(S)
Brian Hoh
(B)
Adam Polifka
(A)
Min Park
(M)
Kimberly Kicielinski
(K)
Sami Al Kasab
(SA)
Eyad Almallouhi
(E)
Michelle Allen
(M)
Jonathan Lena
(J)
Daniel A Hoit
(DA)
Lucas Elijovich
(L)
Violiza Inoa
(V)
Christopher Nickele
(C)
Informations de copyright
© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.
Déclaration de conflit d'intérêts
Competing interests: RMS: consulting and teaching agreements with Penumbra, Abbott, Medtronic, InNeuroCo, and Cerenovus. MNP: travel grants/honoraria from Phenox, Stryker, and Siemens. ASA: consultant for Balt, Johnson and Johnson, Leica, Medtronic, Microvention, Penumbra, Scientia, Siemens, and Stryker; research support for Cerenovus, Microvention, Penumbra, and Siemens; and shareholder of Bendit, Cerebrotech, Endostream, Magneto, Marblehead, Neurogami, Serenity, Synchron, Triad Medical, and Vascular Simulations. LE: consultant for Balt, Cerenovuc, Medtronic, MicroVention, Penumbra, Sequent, and Stryker; and research support for Siemens. PJ: consultant for Medtronics and Microvention. AMS: consultant for Penumbra, Microvention, and Pulsar Vascular; and travel grants/honoraria from Penumbra, Pulsar Vascular, Microvention, and Stryker. KMF, JM, PK, and RDL are on the editorial board of Journal of Neurointerventional Surgery.