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Original research
Bridging thrombolysis in atrial fibrillation stroke is associated with increased hemorrhagic complications without improved outcomes
  1. Feras Akbik1,2,
  2. Ali Alawieh1,3,
  3. Laurie Dimisko1,
  4. Brian M Howard1,
  5. C Michael Cawley1,
  6. Frank C Tong1,
  7. Fadi Nahab2,
  8. Owen B Samuels1,
  9. Ilko Maier4,
  10. Wuwei Feng5,
  11. Nitin Goyal6,
  12. Robert M Starke7,
  13. Ansaar Rai8,
  14. Kyle M Fargen9,
  15. Marios N Psychogios10,
  16. Pascal Jabbour11,
  17. Reade De Leacy12,
  18. Saleh G Keyrouz13,
  19. Travis M Dumont14,
  20. Peter Kan15,
  21. Jan Liman16,
  22. Adam S Arthur6,
  23. Stacey Q Wolfe9,
  24. J Mocco12,
  25. Roberto Javier Crosa17,
  26. W Christopher Fox18,
  27. Benjamin Gory19,20,
  28. Alejandro M Spiotta3,
  29. Jonathan A Grossberg1
  30. Stroke Thrombectomy and Aneurysm Registry (STAR) Collaborators
    1. 1 Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
    2. 2 Department of Neurology, Emory University, Atlanta, Georgia, USA
    3. 3 Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
    4. 4 Neurology, University Medicine Goettingen, Goettingen, Germany
    5. 5 Neurology, Duke University Medical Center, Durham, North Carolina, USA
    6. 6 Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
    7. 7 Neurosurgery and Radiology, University of Miami, Miller School of Medicine, Miami, Florida, USA
    8. 8 Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
    9. 9 Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
    10. 10 Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
    11. 11 Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
    12. 12 Neurosurgery, The Mount Sinai Health System, New York, New York, USA
    13. 13 Department of Neurology, Washington University at St. Louis, St Louis, Missouri, USA
    14. 14 Surgery, Division of Neurosurgery, Banner University of Arizona Medical Center, Tucson, Arizona, USA
    15. 15 Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
    16. 16 Neurology, University Medical Center, Göttingen, Germany
    17. 17 Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Uruguay
    18. 18 Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
    19. 19 Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France
    20. 20 INSERM, IADI, Université de Lorraine, Nancy, France
    1. Correspondence to Dr Jonathan A Grossberg, Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, GA 30303, USA; jonathan.a.grossberg{at}


    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.

    • stroke
    • thrombectomy
    • thrombolysis

    Data availability statement

    Data are available upon reasonable request. Data are available upon reasonable request

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    Data availability statement

    Data are available upon reasonable request. Data are available upon reasonable request

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    • Twitter @feras.akbik, @BrianHoward_MD, @Starke_neurosurgery, @PascalJabbourMD, @rdeleacymd, @PeterKa80460001, @AdamArthurMD, @wchrisfox

    • FA and AA contributed equally.

    • Collaborators Stroke Thrombectomy and Aneurysm Registry (STAR) Collaborators: Sébastien Richard, Brian Hoh, Adam Polifka, Min Park, Kimberly Kicielinski, Sami Al Kasab, Eyad Almallouhi, Michelle Allen, Jonathan Lena, Daniel A Hoit, Lucas Elijovich, Violiza Inoa, Christopher Nickele.

    • Contributors FA, AA, JAG, and AMS designed the research study. AA, BMH, CMC, FCT, FN, OBS, IM, WF, NG, RMS, AR, KMF, MNP, PJ, RDL, SGK, TMD, PK, JL, ASA, SQW, JM, RJC, WCF, BG, AMS, and JAG participated in data acquisition and will act as the author guarantor. FA, AA, LD, JAG, and AMS participated in data analysis. All authors participated in interpretation of the data and critical revision of the manuscript.

    • Funding Partially funded through the National Institutes of Health National Institute of Nursing Research grant No T32NR012715 (principal investigators: S Dunbar and M Song) for trainee LD. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

    • 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.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.