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Differential effect of mechanical thrombectomy and intravenous thrombolysis in atrial fibrillation associated stroke
  1. Feras Akbik1,
  2. Ali Alawieh2,
  3. C Michael Cawley2,
  4. Brian M Howard3,4,
  5. Frank C Tong5,
  6. Fadi Nahab6,
  7. Hassan Saad2,
  8. Laurie Dimisko7,
  9. Christian Mustroph2,
  10. Owen B Samuels1,
  11. Gustavo Pradilla2,
  12. Ilko Maier8,
  13. Nitin Goyal9,
  14. Robert M Starke10,
  15. Ansaar Rai11,
  16. Kyle M Fargen12,
  17. Marios N Psychogios13,
  18. Pascal Jabbour14,
  19. Reade De Leacy15,
  20. James Giles16,
  21. Travis M Dumont17,
  22. Peter Kan18,
  23. Adam S Arthur19,20,
  24. Roberto Javier Crosa21,
  25. Benjamin Gory22,
  26. Alejandro M Spiotta23,
  27. Jonathan A Grossberg24
  28. Stroke Thrombectomy and Aneurysm Registry (STAR)
    1. 1Department of Neurology, Neurosurgery, Emory University, Atlanta, Georgia, USA
    2. 2Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
    3. 3Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
    4. 4Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
    5. 5Department of Radiology, Emory University, Altanta, Georgia, USA
    6. 6Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
    7. 7Emory Healthcare, Atlanta, Georgia, USA
    8. 8Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
    9. 9Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
    10. 10Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami Beach, Florida, USA
    11. 11Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
    12. 12Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
    13. 13Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
    14. 14Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
    15. 15Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
    16. 16Department of Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
    17. 17Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
    18. 18Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
    19. 19Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
    20. 20Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
    21. 21Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
    22. 22Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
    23. 23Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
    24. 24Department of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
    1. Correspondence to Dr Jonathan A Grossberg, Department of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, GA 30322, USA; jonathan.a.grossberg{at}; Dr Alejandro M Spiotta, Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA; spiotta{at}


    Background Atrial fibrillation (AF) associated ischemic stroke has worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Limited data exist about the effect of AF on procedural and clinical outcomes after mechanical thrombectomy (MT).

    Objective To determine whether recanalization efficacy, procedural speed, and clinical outcomes differ in AF associated stroke treated with MT.

    Methods We performed a retrospective cohort study of the Stroke Thrombectomy and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4169 patients who underwent MT for an anterior circulation stroke, 1517 (36.4 %) of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared.

    Results AF predicted faster procedural times, fewer passes, and higher rates of first pass success on multivariate analysis (p<0.01). AF had no effect on intracranial hemorrhage (aOR 0.69, 95% CI 0.43 to 1.12) or 90-day functional outcomes (aOR 1.17, 95% CI 0.91 to 1.50) after MT, although patients with AF were less likely to receive IVT (46% vs 54%, p<0.0001).

    Conclusions In patients treated with MT, comorbid AF is associated with faster procedural time, fewer passes, and increased rates of first pass success without increased risk of intracranial hemorrhage or worse functional outcomes. These results are in contrast to the increased hemorrhage rates and worse functional outcomes observed in AF associated stroke treated with supportive care and or IVT. These data suggest that MT negates the AF penalty in ischemic stroke.

    • stroke
    • thrombectomy
    • thrombolysis
    • hemorrhage

    Statistics from


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

    • FA and AA contributed equally.

    • AMS and JAG contributed equally.

    • Collaborators Stroke Thrombectomy and Aneurysm Registry (STAR): Jan Liman; David J Mccarthy; Vasu Saini; Stacey Q Wolfe; J Mocco; Johanna T Fifi; Fábio A Nascimento; Ahmad Sweid; Salah G Keyrouz; Wuwei Feng; Reda M Chalhoub; 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 project, acquired data, analyzed the data, and wrote the manuscript. CMC, BMH, FCT, FN, HS, LD, CM, OBS, and GP contributed to data acquisition, interpretation, and critical review. IM, NG, RMS, AR, KMF, MNP, PJ, RDL, JG, TMD, PK, ASA, RJC, and BG contributed to data interpretation and critical review of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests RMS: consulting and teaching agreements with Penumbra, Abbott, Medtronic, InNeuroCo, and Cerenovus. MNP: travel grants/honoraria–Phenox, Stryker, Siemens. ASA: consultant–Balt, Johnson and Johnson, Leica, Medtronic, Microvention, Penumbra, Scientia, Siemens, and Stryker; research support–Cerenovus, Microvention, Penumbra, and Siemens; and shareholder–Bendit, Cerebrotech, Endostream, Magneto, Marblehead, Neurogami, Serenity, Synchron, Triad Medical, Vascular Simulations. PJ: consultant-Medtronics, Microvention. AMS: consultant–Penumbra, Microvention, and Pulsar Vascular; travel grants/honoraria–Penumbra, Pulsar Vascular, Microvention, Stryker. AR: consulting agreement with Stryker, Cerenovus, and Microvention.

    • Patient consent for publication Not required.

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

    • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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