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  • Impact of atrial fibrillation on the treatment effect of bridging thrombolysis in ischemic stroke patients undergoing endovascular thrombectomy: a multicenter international cohort study

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Vascular neurology
Impact of atrial fibrillation on the treatment effect of bridging thrombolysis in ischemic stroke patients undergoing endovascular thrombectomy: a multicenter international cohort study
  1. Jing Hong Loo1,
  2. Aloysius ST Leow2,
  3. Mingxue Jing2,
  4. Ching-Hui Sia3,4,
  5. Bernard PL Chan1,5,
  6. Raymond CS Seet1,6,
  7. Hock-Luen Teoh1,5,
  8. Lukas Meyer7,
  9. Jens Fiehler8,
  10. Panagiotis Papanagiotou9,10,
  11. Andreas Kastrup11,
  12. Anastasios Mpotsaris12,
  13. Volker Maus13,
  14. Furkan Yapici13,
  15. Davide Simonato14,
  16. Joseph D Gabrieli14,
  17. Giacomo Cester14,
  18. Pervinder Bhogal15,
  19. Oliver Spooner15,
  20. Christos Nikola15,
  21. Abhishek Joshi15,
  22. Tsong-Hai Lee16,
  23. Jiale Wu17,
  24. Yimin Chen18,
  25. Shuiquan Yang18,
  26. Vijay Kumar Sharma1,5,
  27. Benjamin YQ Tan1,5,
  28. Leonard LL Yeo1,5
  1. 1 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  2. 2 National University Health System Singapore, Singapore
  3. 3 National University of Singapore, Singapore
  4. 4 Department of Cardiology, National University Heart Centre, Singapore
  5. 5 Division of Neurology, Department of Medicine, National University Hospital, Singapore
  6. 6 Department of Medicine, Division of Neurology, National University Hospital, Singapore
  7. 7 Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  8. 8 Department of Neuroradiology, Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  9. 9 Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany
  10. 10 First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece
  11. 11 Department of Neurology, Hospital Bremen-Mitte, Bremen, Germany
  12. 12 Department of Neuroradiology, University Hospital Magdeburg, Bochum, Germany
  13. 13 Department of Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Langendreer, Ruhr-University Bochum, Bochum, Germany
  14. 14 Departmento of Neuroradiology, University Hospital of Padua, Padua, Italy
  15. 15 Department of Stroke Medicine, Royal London Hospital, London, UK
  16. 16 Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
  17. 17 School of Medicine, Shaoguan University, Shaoguan, Guangdong, China
  18. 18 Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China
  1. Correspondence to Dr Leonard LL Yeo, Division of Neurology, Department of Medicine, National University Hospital, 119074, Singapore; leonardyeoll{at}gmail.com

Abstract

Background The role of bridging intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in the treatment of acute ischemic stroke (AIS) remains debatable. Atrial fibrillation (AF) associated strokes may be associated with reduced treatment effect from IVT. This study compares the effect of bridging IVT in AF and non-AF patients.

Methods This retrospective cohort study comprised anterior circulation large vessel occlusion (LVO) AIS patients receiving EVT alone or bridging IVT plus EVT within 6 hours of symptom onset. Primary outcome was good functional outcome defined as modified Rankin Scale (mRS) 0–2 at 90 days. Secondary outcomes were successful reperfusion defined as expanded Thrombolysis In Cerebral Infarction (eTICI) grading ≥2b flow, symptomatic intracerebral hemorrhage (sICH), and in-hospital mortality.

Results We included 705 patients (314 AF and 391 non-AF patients). The mean age was 68.6 years and 53.9% were male. The odds of good functional outcomes with bridging IVT was higher in the non-AF (adjusted odds ratio (aOR) 2.28, 95% CI 1.06 to 4.91, P=0.035) compared with the AF subgroups (aOR 1.89, 95% CI 0.89 to 4.01, P=0.097). However, this did not constitute a significant effect modification by the presence of AF on bridging IVT (interaction aOR 0.12, 95% CI −1.94 to 2.18, P=0.455). The rate of successful reperfusion, sICH, and mortality were similar between bridging IVT and EVT for both AF and non-AF patients.

Conclusion The presence of AF did not modify the treatment effect of bridging IVT. Further individual patient data meta-analysis of randomized trials may shed light on the comparative efficacy of bridging IVT in AF versus non-AF LVO strokes.

  • thrombectomy
  • stroke
  • thrombolysis

Data availability statement

Data are available upon reasonable request.

https://doi.org/10.1136/jnis-2022-019590

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    Data availability statement

    Data are available upon reasonable request.

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    Footnotes

    • JHL and ASL are joint first authors.

    • BYT and LLY are joint senior authors.

    • Twitter @Fie0815

    • Contributors JHL, ASL: methodology, investigation, acquisition of data, data analysis, software, writing – original draft, writing – review and editing, visualization, approval of manuscript. MJ, CS, BPC, RCS, HLT, LM, JF, PP, AK, AM, VM, FY, DS, JSG, GC, PB, OS, CN, AJ, TL, JW, YC, SY, VKS: writing – review and editing, approval of manuscript. BYQT, LLY: conceptualization, methodology, writing – review and editing, approval of manuscript, guarantor of the study.

    • Funding RCS: funding from National Medical Research Council (NMRC), Singapore. BYT: funding from ExxonMobil-NUS Research Fellowship for Clinicians, Ministry of Health Healthcare Research Scholarship - Master of Clinical Investigation (MCI) Program, National Medical Research Council (NMRC), Singapore. LLY: funding from National Medical Research Council (NMRC), Singapore.

    • Competing interests RCS: honoraria from Pfizer, AstraZeneca, Schwabe. LM: compensation as a speaker for Balt Prime. JF: editorial board of Journal of NeuroInterventional Surgery, ESMINT president; consulting agreements with Cerenovus, Medtronic, Phenox, Penumbra, Roche, Tonbridge; advisory boards of Stryker, Phenox. GC: honoraria and personal payment from Penumbra. PB: consulting agreements with Perflow Medical, Brainomix, Balt, Stryker, Phenox, Neurovasc; honoraria from Perflow Medical, Brainomix, Stryker, Cerenovus. LLY: vice president of Singapore Neurointerventional Society.

    • 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.