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  • Prior anticoagulation and bridging thrombolysis improve outcomes in patients with atrial fibrillation undergoing endovascular thrombectomy for anterior circulation stroke

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Ischemic stroke
Original research
Prior anticoagulation and bridging thrombolysis improve outcomes in patients with atrial fibrillation undergoing endovascular thrombectomy for anterior circulation stroke
  1. Longting Lin1,2,
  2. Christopher Blair1,2,
  3. James Fu1,
  4. Dennis Cordato1,2,3,
  5. Cecilia Cappelen-Smith1,2,3,
  6. Andrew Cheung1,4,5,6,
  7. Nathan W Manning1,4,5,6,
  8. Jason Wenderoth1,4,5,6,
  9. Chushuang Chen7,
  10. Andrew Bivard2,8,
  11. Kenneth Butcher5,
  12. Timothy J Kleinig9,
  13. Philip Choi10,
  14. Christopher R Levi7,
  15. Mark Parsons1,2,3
  16. on behalf of INSPIRE study group
    1. 1 South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
    2. 2 Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
    3. 3 Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia
    4. 4 Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia
    5. 5 Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
    6. 6 Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
    7. 7 Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
    8. 8 Melbourne Brain Centre, University of Melbourne, Melbourne, Victoria, Australia
    9. 9 Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
    10. 10 Department of Neurology, Eastern Health Box Hill, Melbourne, Victoria, Australia
    1. Correspondence to Dr Mark Parsons, University of New South Wales, Sydney, New South Wales, Australia; mark.parsons{at}unsw.edu.au

    Abstract

    Background Where stroke occurs with pre-existing atrial fibrillation (AF)studies validating the safety and efficacy of bridging thrombolysis, and the use of endovascular thrombectomy (EVT) in the setting of prior anticoagulation, are limited to single-center reports.

    Methods In a retrospective analysis, AF patients undergoing EVT for anterior circulation large vessel occlusion stroke enrolled in a prospectively-maintained, international multicenter database (International Stroke Perfusion Imaging Registry (INSPIRE)) between 2016 and 2019 were studied. Patients were categorized by anticoagulation status: anticoagulated (warfarin/non-vitamin K oral anticoagulants) versus not anticoagulated. Patients not anticoagulated were further divided into intravenous thrombolysis versus no thrombolysis. Outcomes compared between groups included 90-day modified Rankin Scale, 90-day mortality, rates of symptomatic intracerebral hemorrhage (sICH), and good reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3).

    Results Of 563 AF patients, 118 (21%) were on anticoagulation. AF patients on anticoagulation showed improved 90-day functional outcomes (adjusted odds ratio (aOR) 1.68, 95% confidence interval (95% CI) 1.00 to 2.82). Mortality (26.3% vs 23.8%), sICH (4.5% vs 3.9%), and rates of good reperfusion (91.3% vs 88.0%) were similar between those anticoagulated and those not anticoagulated. Thrombolysis before EVT in AF patients was independently associated with improved 90-day functional outcomes (aOR 1.81, 95% CI 1.18 to 2.79) and reduced mortality (aOR 0.51, 95% CI 0.31 to 0.84), with similar sICH rates (3.4% vs 4.5%).

    Conclusions Anticoagulated patients with AF who underwent EVT had improved 90-day functional outcomes and similar sICH rates. Thrombolysis before EVT in AF patients was associated with improved 90-day functional outcomes and reduced mortality.

    • Stroke
    • Thrombolysis
    • Thrombectomy

    Data availability statement

    Data are available upon reasonable request. Data pertaining to this study can be made available on reasonable request.

    https://doi.org/10.1136/jnis-2022-019560

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      Data availability statement

      Data are available upon reasonable request. Data pertaining to this study can be made available on reasonable request.

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      Footnotes

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      • Collaborators INSPIRE Study Group members: Christopher R. Levi, MD (John Hunter Hospital, Newcastle, Australia); Neil J. Spratt, MD (John Hunter Hospital, Newcastle, Australia); Carlos Garcia-Esperon, MD, PhD (John Hunter Hospital, Newcastle, Australia); Ferdinand Miteff, MD (John Hunter Hospital, Newcastle, Australia); Philip M. C. Choi, MD (Eastern Health, Box Hill, Melbourne, Australia); Timothy Kleining, PhD, MD (Royal Adelaide Hospital, Adelaide, Australia); Billy O’Brien, MD (Gosford Hospital, Gosford, Australia); Kenneth Butcher, MD, PhD (Prince of Wales Clinical School, University of New South Wales, Sydney, Australia); Jianhong Yang, MD (Ningbo First Hospital, Ningbo, Zhejiang, China); Congguo Yin, MD (Hangzhou First Hospital, Zhejiang University School of Medicine, Hangzhou, China); Peng Wang, MD (Zhejiang Provincial People’s Hospital, Hangzhou, China); Yu Geng, MD (Zhejiang Provincial People’s Hospital, Hangzhou, China); Xuezhi Yang, MD (The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China); Qi Fang, MD (The First Affiliated Hospital of Soochow University, Soochow, China); Yi Sui, PhD, MD (The First People’s Hospital of Shenyang, Shenyang, China); Wenhuo Chen, MD (Zhangzhou Municipal Hospital, Zhangzhou, China); Xin Cheng, MD (Huashan Hospital, Fudan University, Shanghai, China); Qiang Dong, MD (Huashan Hospital, Fudan University, Shanghai, China); Gang Li, MD, PhD (Shanghai East Hospital, Tongji University, Shanghai, China).

      • Contributors All of the above authors fulfill the following authorship criteria: Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND Drafting the work or revising it critically for important intellectual content; AND Final approval of the version to be published; AND Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

        The guarantor (MP) accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

      • 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; 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.