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Original research
Mildly elevated INR is associated with worse outcomes following mechanical thrombectomy for acute ischemic stroke
  1. Huanwen Chen1,2,
  2. Ghasan Ahmad3,
  3. Marco Colasurdo3,
  4. Karen Yarbrough2,
  5. Chad Schrier2,
  6. Michael S Phipps2,
  7. Carolyn A Cronin2,
  8. Prachi Mehndiratta2,
  9. John W Cole2,
  10. Marcella Wozniak2,
  11. Timothy R Miller3,
  12. Dheeraj Gandhi3,
  13. Gaurav Jindal3,
  14. Seemant Chaturvedi2
  1. 1National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
  2. 2Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
  3. 3Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
  1. Correspondence to Dr Seemant Chaturvedi, University of Maryland Medical Center, Baltimore, MD 21201, USA; schaturvedi{at}som.umaryland.edu

Abstract

Background Elevated International Normalized Ratio (INR) is a marker of coagulopathy, but its impact on outcomes following mechanical thrombectomy (MT) in patients with stroke is unclear. This study investigates the impact of mild INR elevations on clinical outcomes following MT.

Methods In this retrospective cohort study, consecutive patients with stroke treated with MT were identified from 2015 to 2020 at a Comprehensive Stroke Center. Demographic information, past medical history, INR, National Institutes of Health Stroke Scale score, use of tissue plasminogen activator, and last known normal to arteriotomy time were recorded. Outcome measures included modified Thrombolysis in Cerebral Infarction (mTICI) score, modified Rankin Scale (mRS) score at 90 days, and intracerebral hemorrhage (ICH). Patients were divided into two groups: normal INR (0.8–1.1) and mildly elevated INR (1.2–1.7).

Results A total of 489 patients were included for analysis, of which 349 had normal INR and 140 had mildly elevated INR. After multivariable adjustments, mildly elevated INR was associated with lower odds of excellent outcomes (mRS 0–1, OR 0.24, p=0.009), lower odds of functional independence (mRS 0–2, OR 0.38, p=0.038), and higher odds of 90-day mortality (OR 3.45, p=0.018). Elevated INR was not associated with a higher likelihood of ICH, and there were no differences in rates of HI1, HI2, PH1, or PH2 hemorrhagic transformations; however, elevated INR was associated with significantly higher odds of 90-day mortality in patients with ICH (OR 6.22, p=0.024). This effect size was larger than in patients without ICH (OR 3.38, p<0.001).

Conclusion In patients with stroke treated with MT, mildly elevated INR is associated with worse clinical outcomes after recanalization and may worsen the mortality risk of hemorrhagic transformations.

  • Intervention
  • Stroke
  • Hemorrhage
  • Thrombectomy

Data availability statement

Data are available upon reasonable request. De-identified patient-level data are available upon reasonable request for research collaborations.

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Data availability statement

Data are available upon reasonable request. De-identified patient-level data are available upon reasonable request for research collaborations.

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Footnotes

  • Contributors HC and SC initiated and designed the study. HC, GA, KY, and CS collected the data. HC and MC analyzed the data. HC, GJ, and SC wrote the manuscript. MSP, CAC, PM, JWC, MW, TRM, and DG revised the manuscript. SC is the guarantor.

  • Funding JWC is partially supported by the NIH (grants R01-NS114045, R01-NS100178, R01-NS105150), an American Heart Association-Bayer Discovery Grant (grant 17IBDG33700328), the AHA Cardiovascular Genome-Phenome Study (grant 15GPSPG23770000), and the US Department of Veterans Affairs.

  • Competing interests None declared.

  • 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.