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.
Data availability statement
Data are available upon reasonable request. Data are available upon reasonable request
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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.
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