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Akbik F, Alawieh A, Dimisko L, Howard BM, Cawley CM, Tong FC, Nahab F, Samuels OB, Maier I, Feng W, Goyal N, Starke RM, Rai A, Fargen KM, Psychogios MN, Jabbour P, De Leacy R, Keyrouz SG, Dumont TM, Kan P, Liman J, Arthur AS, Wolfe SQ, Mocco J, Crosa RJ, Fox WC, Gory B, Spiotta AM, Grossberg JA. Bridging thrombolysis in atrial fibrillation stroke is associated with increased hemorrhagic complications without improved outcomes. J Neurointerv Surg 2021; 14:979-984. [PMID: 34819345 DOI: 10.1136/neurintsurg-2021-017954] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/27/2021] [Indexed: 01/02/2023]
Abstract
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 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 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 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.
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Affiliation(s)
- Feras Akbik
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.,Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.,Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Laurie Dimisko
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Frank C Tong
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Fadi Nahab
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Owen B Samuels
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, Germany
| | - Wuwei Feng
- Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Nitin Goyal
- Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Robert M Starke
- Neurosurgery and Radiology, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Ansaar Rai
- Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Reade De Leacy
- Neurosurgery, The Mount Sinai Health System, New York, New York, USA
| | - Saleh G Keyrouz
- Department of Neurology, Washington University at St. Louis, St Louis, Missouri, USA
| | - Travis M Dumont
- Surgery, Division of Neurosurgery, Banner University of Arizona Medical Center, Tucson, Arizona, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Jan Liman
- Neurology, University Medical Center, Göttingen, Germany
| | - Adam S Arthur
- Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - J Mocco
- Neurosurgery, The Mount Sinai Health System, New York, New York, USA
| | | | - W Christopher Fox
- Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France.,INSERM, IADI, Université de Lorraine, Nancy, France
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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