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Original research
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. 1Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  2. 2National University Health System Singapore, Singapore
  3. 3National University of Singapore, Singapore
  4. 4Department of Cardiology, National University Heart Centre, Singapore
  5. 5Division of Neurology, Department of Medicine, National University Hospital, Singapore
  6. 6Department of Medicine, Division of Neurology, National University Hospital, Singapore
  7. 7Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  8. 8Department of Neuroradiology, Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  9. 9Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany
  10. 10First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece
  11. 11Department of Neurology, Hospital Bremen-Mitte, Bremen, Germany
  12. 12Department of Neuroradiology, University Hospital Magdeburg, Bochum, Germany
  13. 13Department of Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Langendreer, Ruhr-University Bochum, Bochum, Germany
  14. 14Departmento of Neuroradiology, University Hospital of Padua, Padua, Italy
  15. 15Department of Stroke Medicine, Royal London Hospital, London, UK
  16. 16Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
  17. 17School of Medicine, Shaoguan University, Shaoguan, Guangdong, China
  18. 18Department 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}


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.

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Data availability statement

Data are available upon reasonable request.

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  • 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.

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