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Intravenous thrombolysis before mechanical thrombectomy in patients with atrial fibrillation
  1. Antonio Bozzani1,
  2. Vittorio Arici1,
  3. Franco Ragni1,
  4. Antonio Sterpetti2,
  5. Eloisa Arbustini1
  1. 1Vascular Surgery and Centre for Inherited Cardiovascular Diseases, Foundation IRCCS Polyclinic San Matteo, Pavia, Lombardia, Italy
  2. 2Surgery, University of Rome La Sapienza, Rome, Italy
  1. Correspondence to Dr Antonio Sterpetti, SURGERY, University of Rome La Sapienza, Rome, Italy; antonio.sterpetti{at}uniroma1.it

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The introduction into clinical practice of endovascular mechanical thrombectomy (MT) has brought better results in patients with ischemic stroke from large vessel occlusion (LVO) in the anterior circulation in whom therapy is started 4.5–5 hours after symptoms onset.1–3 Controversies exist about the usefulness of intravenous thrombolysis (IVT) before MT in patients with atrial fibrillation (AF). AF is the probable etiology in >25% of ischemic strokes, and >40% of patients with ischemic stroke from LVO in the anterior circulation have a clinical history of AF.4 5 AF is an independent predictor of poor functional outcome and increased mortality after an ischemic stroke. This is partly explained by covariate older age and associated comorbidities; however, AF-associated strokes involve larger infarct volumes.5

Conceptually IVT before MT might increase the risk for intracranial hemorrhage and favor distal migration of thrombi. On the other hand, immediate IVT may reduce the time of cerebral ischemia, IVT being a simple initial therapeutic choice while the patient is evaluated as a potential candidate for endovascular MT. Disability despite revascularization is frequent and related with time-dependent irreversible injury to some brain tissue. It is possible that a substantial volume of brain tissue could have been already irreversibly injured in some patients by the time reperfusion occurs. The longer the time of cerebral ischemia the higher the possibility of endothelial damage with consequent reduced nitrogen dioxide (NO2) production and vasoconstriction, and impaired antithrombotic function.1 2

A recent article Akbik et al6 analyzed retrospectively the clinical outcomes of 6461 patients who 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 …

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Footnotes

  • Contributors AS: conceived the idea and wrote the manuscript. AB: collected the data. VA: collected the data and performed the analysis. FR: reviewed the paper and gave suggestions. EA: reviewed the paper and gave suggestions.

  • 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 None declared.

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