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Zhang H, Chen S, Zhu Q, Li Z, Lv T, Liu C. Mechanical Thrombectomy in Anticoagulated Patients With Acute Ischemic Stroke: A Meta-Analysis. Neurologist 2024; 29:194-203. [PMID: 38019090 DOI: 10.1097/nrl.0000000000000542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
BACKGROUND According to a previous studies, mechanical thrombectomy(MT) is safe for anticoagulated patients. However, the safety and prognosis of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKA) have not been compared with those of MT.This meta-analysis aimed at determining the efficacy of DOACs or VKA for patients after MT. REVIEW SUMMARY We searched PubMed, Embase, Web of Science databases, and Cochrane from their inception to Aug 2022. Revman 5.3 served for the meta-analysis. The meta-analysis included 12 studies that covered 3571 patients, finding that after MT treatment, DOACs significantly decreased the symptomatic intracerebral hemorrhage [odd ratio (OR)=0.49, 95% CI 0.30-0.80, P =0.004] and mortality (OR=0.63, 95% CI 0.48-0.83, P =0.001) compared with VKA. Meanwhile, no obvious differences were found between DOACs and VKA after MT treatment in terms of in any hemorrhagic transformation (OR=1.07, 95% CI 0.84-1.37, P =0.59), good functional outcome (OR=1.06, 95% CI 0.88-1.27, P =0.53), and successful arterial recanalization (OR=1.24, 95% CI 1.00-1.53, P =0.05). CONCLUSIONS This meta-analysis demonstrates that the application of DOACs in MT treatment for anticoagulated patients with acute ischemic stroke is safer than that in the VKA group. However, further studies are necessary to confirm these results.
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Affiliation(s)
| | - Shiqin Chen
- Department of Neurology, Second People's Hospital of Yuhuan, Yuhuan
| | - QianYuan Zhu
- Department of Neurology, Fenghua Hospital of Traditional Chinese Medicine, Ningbo
| | - ZongShan Li
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou
| | - Tian Lv
- Neurology, Zhuji Affiliated Hospital of Wenzhou Medical University, Zhuji
| | - Chengjiang Liu
- Department of General Medicine, Affiliated Anqing First People's Hospital of Anhui Medical University, AnQing, China
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2
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Lin L, Blair C, Fu J, Cordato D, Cappelen-Smith C, Cheung A, Manning NW, Wenderoth J, Chen C, Bivard A, Butcher K, Kleinig TJ, Choi P, Levi CR, Parsons M. Prior anticoagulation and bridging thrombolysis improve outcomes in patients with atrial fibrillation undergoing endovascular thrombectomy for anterior circulation stroke. J Neurointerv Surg 2023; 15:e433-e437. [PMID: 36944493 DOI: 10.1136/jnis-2022-019560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023]
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.
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Affiliation(s)
- Longting Lin
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Christopher Blair
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - James Fu
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Dennis Cordato
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Cecilia Cappelen-Smith
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Andrew Cheung
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia
- Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
- Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Nathan W Manning
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia
- Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
- Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Jason Wenderoth
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia
- Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
- Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Chushuang Chen
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Andrew Bivard
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Melbourne Brain Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Kenneth Butcher
- Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Philip Choi
- Department of Neurology, Eastern Health Box Hill, Melbourne, Victoria, Australia
| | - Christopher R Levi
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Mark Parsons
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia
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3
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D'Anna L, Romoli M, Foschi M, Abu-Rumeileh S, Dolkar T, Vittay O, Dixon L, Bentley P, Brown Z, Hall C, Jamil S, Jenkins H, Kwan J, La Cava R, Patel M, Rane N, Roi D, Singh A, Venter M, Halse O, Malik A, Kalladka D, Banerjee S, Lobotesis K. Outcomes of mechanical thrombectomy in orally anticoagulated patients with anterior circulation large vessel occlusion: a propensity-matched analysis of the Imperial College Thrombectomy Registry. J Neurol 2023; 270:5827-5834. [PMID: 37596423 PMCID: PMC10632297 DOI: 10.1007/s00415-023-11926-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/06/2023] [Accepted: 08/07/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) remains an effective treatment for patients with acute ischemic stroke receiving oral anticoagulation (OAC) and large vessel occlusion (LVO). However, to date, it remains unclear whether MT is safe in patients on treatment with OAC. AIMS In our study, we performed a propensity-matched analysis to investigate the safety and efficacy of MT in patients with acute ischemic stroke receiving anticoagulants. A propensity score method was used to target the causal inference of the observational study design. METHODS This observational, prospective, single-centre study included consecutive patients with acute LVO ischemic stroke of the anterior circulation. Demographic, neuro-imaging and clinical data were collected and compared according to the anticoagulation status at baseline, patients on OAC vs those not on OAC. The primary study outcomes were the occurrence of any intracerebral haemorrhage (ICH) and symptomatic ICH. The secondary study outcomes were functional independence at 90 days after stroke (defined as modified Rankin Scale (mRS) scores of 0 through 2), mortality at 3 months and successful reperfusion rate according to the modified treatment in cerebral infarction (mTICI) score. RESULTS Overall, our cohort included 573 patients with acute ischemic stroke and LVO treated with MT. After propensity score matching, 495 patients were matched (99 OAC group vs 396 no OAC group). There were no differences in terms of clinical characteristics between the two groups, except for the rate of intravenous thrombolysis less frequently given in the OAC group. There was no significant difference in terms of the rate of any ICH and symptomatic ICH between the two groups. With regards to the secondary study outcome, there was no significant difference in terms of the rate of successful recanalization post-procedure and functional independence at 3 months between the two groups. Patients in the OAC group showed a reduced mortality rate at 90 days compared to the patients with no previous use of anticoagulation (20.2% vs 21.2%, p = 0.031). Logistic regression analysis did not reveal a statistically significant influence of the anticoagulation status on the likelihood of any ICH (OR = 0.95, 95% CI = 0.46-1.97, p = 0.900) and symptomatic ICH (OR = 4.87, 95% CI = 0.64-37.1, p = 0.127). Our analysis showed also that pre-admission anticoagulant use was not associated with functional independence at 90 days after stroke (OR = 0.76, 95% CI = 0.39-1.48, p = 0.422) and rate of successful reperfusion (OR = 0.81, 95% CI = 0.38-1.72, p = 0.582). CONCLUSION According to our findings anticoagulation status at baseline did not raise any suggestion of safety and efficacy concerns when MT treatment is provided according to the standard guidelines. Confirmation of these results in larger controlled prospective cohorts is necessary.
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Affiliation(s)
- Lucio D'Anna
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK.
- Department of Brain Sciences, Imperial College London, London, UK.
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Samir Abu-Rumeileh
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Tsering Dolkar
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Orsolya Vittay
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Luke Dixon
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Paul Bentley
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Zoe Brown
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Charles Hall
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Sohaa Jamil
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Harri Jenkins
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Joseph Kwan
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Roberta La Cava
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Maneesh Patel
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Neil Rane
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Dylan Roi
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Abhinav Singh
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Marius Venter
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Omid Halse
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Abid Malik
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Dheeraj Kalladka
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Soma Banerjee
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
| | - Kyriakos Lobotesis
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
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Li W, Xing X, Wen C, Liu H. Risk factors and functional outcome were associated with hemorrhagic transformation after mechanical thrombectomy for acute large vessel occlusion stroke. J Neurosurg Sci 2023; 67:585-590. [PMID: 33320467 DOI: 10.23736/s0390-5616.20.05141-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Risk factors and functional outcome of hemorrhagic transformation (HT) after mechanical thrombectomy (MT) are to be elucidated in patients with acute large vessel occlusion stroke. METHODS We retrospectively analyzed data from 88 patients who underwent MT treatment. Independent risk factors of hemorrhagic infarction (HI), parenchymal hematoma (PH) and symptomatic intracranial hemorrhage (sICH) were implemented to determine. Association between HI, PH, sICH and mortality at 90 days after treatment were analyzed. RESULTS Of 88 patients, 44.3%had HT (N.=39). 64.1% had HI (N.=25), 35.9% had PH (N.=14) and 12.5% had sICH (N.=11). Independent risk factors for HI were associated with higher NIHSS Score (OR 1.190; 95% CI 1.073~1.319, P=0.001, per 1 score increase), history of coronary heart disease (OR 4.645; 95% CI 1.092~19.758, P=0.038), and use of intravenous thrombolysis (OR 3.438; 95% CI 1.029~11.483, P=0.045). Independent risk factors for PH were associated with higher NIHSS Score (OR 1.227; 95% CI 1.085~1.387, P=0.001, per 1 score increase) and history of oral antiplatelet and/or anticoagulation drugs (OR 6.694; 95% CI 1.245~35.977, P=0.027). Independent risk factors for sICH were associated with higher NIHSS Score (OR 1.393; 95% CI 1.138~1.704, P=0.001, per 1 score increase), increased systolic blood pressure (OR 1.061; 95% CI 1.006~1.120, P=0.030, per 1 mmHg increase) and history of coronary heart disease (OR 13.699; 95% CI 1.019~184.098, P=0.048). Patients who had PH were more likely to cause mortality at 90 days (OR 10.15; 95% CI 1.455~70.914, P=0.019). CONCLUSIONS Higher NIHSS Score was associated with HI, PH, and sICH. History of coronary heart was associated with HI and sICH. Use of intravenous thrombolysis was associated with HI. History of oral antiplatelet and/or anticoagulation drugs was associated with PH. Increased systolic blood pressure was associated with sICH. PHs was remarkably associated with mortality at 90 days.
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Affiliation(s)
- Weirong Li
- Department of Neurology, Tai Yuan Central Hospital, Shanxi Medical University, Taiyuan, China
| | - Xiaolian Xing
- Department of Neurology, Tai Yuan Central Hospital, Shanxi Medical University, Taiyuan, China
| | - Chao Wen
- Department of Neurology, Tai Yuan Central Hospital, Shanxi Medical University, Taiyuan, China
| | - Hongwei Liu
- Department of Neurology, Tai Yuan Central Hospital, Shanxi Medical University, Taiyuan, China -
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5
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Amllay A, Becerril-Gaitan A, Hunt A, Jain P, Chen CJ, El Naamani K, Abbas R, Rudick L, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM. Safety of Mechanical Thrombectomy in Patients on Antiplatelet/Anticoagulation. World Neurosurg 2023; 176:e476-e484. [PMID: 37257646 DOI: 10.1016/j.wneu.2023.05.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is performed in patients who are already on anticoagulation (AC)/antiplatelet therapy (AP). However, data are insufficient regarding MT's safety and efficacy profiles in these patients. OBJECTIVE Investigate the outcome of stroke patients already on anticoagulation/antiplatelet receiving MT. METHODS We included consecutive acute ischemic stroke patients treated with MT for 10 years (2012-2022) in a comprehensive stroke center. Baseline variables, efficacy (recanalization [Thrombolysis in Cerebral Infraction] ≥ 2b), good functional outcome (modified Ranking Scale ≤ 2 at 3 months), and safety (symptomatic intracranial hemorrhage [sICH], mortality rates) were evaluated. Additionally, we conducted a subgroup analysis of patients with prior single-AP versus DAPT. RESULTS Six hundred forty-six patients were included (54.5% women, median age 71 years), 84 (13%) were on AC, 196 (30.3%) on AP, and 366 (56.7%) in the control group. The AC and AP groups were older and had more comorbidities. sICH occurred in 7.3% of cases. There was no significant difference in sICH incidence across the groups. The AC group had a lower rate of intravenous thrombolysis (15.9%; P < 0.001), a higher rate of sICH (11.9% vs. AP 7.7% and control 6%; P = 0.172), and higher mortality at discharge (17.9% vs. AP 8.7% and control 10.4%; P = 0.07). However, the groups had similar functional outcomes and mortality rates at 3 months. Successful recanalization was achieved in 92.7% and was similar across groups. Multivariable logistic regression and the subgroup analysis (single-AP vs. dual AP) did not reveal statistically significant associations. CONCLUSIONS MT in patients with prior anticoagulation and AP presenting with acute ischemic strokeis feasible, effective, and safe.
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Affiliation(s)
- Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Levi Rudick
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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Mac Grory B, Holmes DN, Matsouaka RA, Shah S, Chang CWJ, Rison R, Jindal J, Holmstedt C, Logan WR, Corral C, Mackey JS, Gee JR, Bonovich D, Walker J, Gropen T, Benesch C, Dissin J, Pandey H, Wang D, Unverdorben M, Hernandez AF, Reeves M, Smith EE, Schwamm LH, Bhatt DL, Saver JL, Fonarow GC, Peterson ED, Xian Y. Recent Vitamin K Antagonist Use and Intracranial Hemorrhage After Endovascular Thrombectomy for Acute Ischemic Stroke. JAMA 2023; 329:2038-2049. [PMID: 37338878 PMCID: PMC10282891 DOI: 10.1001/jama.2023.8073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/25/2023] [Indexed: 06/21/2023]
Abstract
Importance Use of oral vitamin K antagonists (VKAs) may place patients undergoing endovascular thrombectomy (EVT) for acute ischemic stroke caused by large vessel occlusion at increased risk of complications. Objective To determine the association between recent use of a VKA and outcomes among patients selected to undergo EVT in clinical practice. Design, Setting, and Participants Retrospective, observational cohort study based on the American Heart Association's Get With the Guidelines-Stroke Program between October 2015 and March 2020. From 594 participating hospitals in the US, 32 715 patients with acute ischemic stroke selected to undergo EVT within 6 hours of time last known to be well were included. Exposure VKA use within the 7 days prior to hospital arrival. Main Outcome and Measures The primary end point was symptomatic intracranial hemorrhage (sICH). Secondary end points included life-threatening systemic hemorrhage, another serious complication, any complications of reperfusion therapy, in-hospital mortality, and in-hospital mortality or discharge to hospice. Results Of 32 715 patients (median age, 72 years; 50.7% female), 3087 (9.4%) had used a VKA (median international normalized ratio [INR], 1.5 [IQR, 1.2-1.9]) and 29 628 had not used a VKA prior to hospital presentation. Overall, prior VKA use was not significantly associated with an increased risk of sICH (211/3087 patients [6.8%] taking a VKA compared with 1904/29 628 patients [6.4%] not taking a VKA; adjusted odds ratio [OR], 1.12 [95% CI, 0.94-1.35]; adjusted risk difference, 0.69% [95% CI, -0.39% to 1.77%]). Among 830 patients taking a VKA with an INR greater than 1.7, sICH risk was significantly higher than in those not taking a VKA (8.3% vs 6.4%; adjusted OR, 1.88 [95% CI, 1.33-2.65]; adjusted risk difference, 4.03% [95% CI, 1.53%-6.53%]), while those with an INR of 1.7 or lower (n = 1585) had no significant difference in the risk of sICH (6.7% vs 6.4%; adjusted OR, 1.24 [95% CI, 0.87-1.76]; adjusted risk difference, 1.13% [95% CI, -0.79% to 3.04%]). Of 5 prespecified secondary end points, none showed a significant difference across VKA-exposed vs VKA-unexposed groups. Conclusions and Relevance Among patients with acute ischemic stroke selected to receive EVT, VKA use within the preceding 7 days was not associated with a significantly increased risk of sICH overall. However, recent VKA use with a presenting INR greater than 1.7 was associated with a significantly increased risk of sICH compared with no use of anticoagulants.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Roland A. Matsouaka
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Shreyansh Shah
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Cherylee W. J. Chang
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Richard Rison
- Department of Neurology, USC Keck School of Medicine, Los Angeles, California
| | - Jenelle Jindal
- Department of Neurology, Peter C. Fung, MD, Stroke Center, El Camino Hospital, Mountain View, California
| | | | - William R. Logan
- Department of Neurology, Mercy Hospital of St Louis, St Louis, Missouri
| | - Candy Corral
- Department of Neurology, Huntington Memorial Hospital, Pasadena, California
| | - Jason S. Mackey
- Department of Neurology, Indiana University School of Medicine, Indianapolis
| | - Joey R. Gee
- Department of Neurology, St Joseph’s Heritage Medical Group, Irvine, California
| | - David Bonovich
- Department of Neurology, Sutter Health, Castro Valley, California
| | - James Walker
- Department of Anesthesiology, Critical Care, and Neurocritical Care, Ascension Via Christi Hospital and University of Kansas School of Medicine, Wichita
| | - Toby Gropen
- Department of Neurology, University of Alabama School of Medicine, Birmingham
| | - Curtis Benesch
- Department of Neurology, University of Rochester School of Medicine, Rochester, New York
| | - Jonathan Dissin
- Department of Neurology, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Hemant Pandey
- Department of Neurology, Banner Baywood Medical Center, Chandler, Arizona
| | - David Wang
- Department of Neurology, OSF Healthcare, Peoria, Illinois
| | - Martin Unverdorben
- Global Specialty Medical Affairs, Daiichi Sankyo Inc, Basking Ridge, New Jersey
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing
| | - Eric E. Smith
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
- Yale School of Medicine, New Haven, Connecticut
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New Nork, New York
| | | | - Gregg C. Fonarow
- Department of Medicine, University of California, Los Angeles
- Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, California
| | - Eric D. Peterson
- Department of Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Population and Data Science, UT Southwestern Medical Center, Dallas, Texas
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7
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Rezai MK, Dalen I, Advani R, Fjetland L, Kurz KD, Sandve KO, Kurz MW. Thrombectomy in large vessel occlusion stroke-Does age matter? Acta Neurol Scand 2022; 146:628-634. [PMID: 36029034 PMCID: PMC9804277 DOI: 10.1111/ane.13691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Endovascular treatment (EVT) is the gold standard treatment for emergent large vessel occlusion (LVO). The benefit of EVT for emergent LVO in elderly patients (>80 years old) is still debated as they have been under-represented in randomized controlled trials. Elderly patients with an emergent LVO are a growing population warranting further study. MATERIALS & METHODS We included 225 consecutive patients treated with EVT for LVO either in the anterior or posterior circulation. The clinical outcome was assessed using the National Institute of Health Stroke Scale (NIHSS). Long-term functional outcome was assessed using 90-day modified ranking scale (mRS). RESULTS Neurological improvement: A five-year higher age predicted a 0.43 higher mean NIHSS score after EVT (p = .027). After adjusting for confounders (influencing variables), the association between age and post-interventional NIHSS was reduced and non-significant (p = .17). At discharge, a five-year higher age predicted a 0.74 higher mean NIHSS (p = .003). After adjusting for confounders this association was reduced and non-significant (p = .06). Long-term functional outcome: A five-year higher age predicted a 0.20 higher mRS at three months (p < .001). When adjusting for confounders this number was reduced to 0.16, yet still highly significant (p < .001). CONCLUSIONS Age seems to have a minor role in predicting neurological improvement after EVT but has an impact on long-term functional outcome. The decision to perform or withhold EVT should therefore not solely be based on age.
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Affiliation(s)
- Mehdi K. Rezai
- Department of NeurologyStavanger University HospitalStavangerNorway,Neuroscience Research GroupStavanger University HospitalStavangerNorway
| | - Ingvild Dalen
- Department of Research, Section of BiostatisticsStavanger University HospitalStavangerNorway
| | - Rajiv Advani
- Neuroscience Research GroupStavanger University HospitalStavangerNorway,Department of Neurology, Stroke UnitOslo University HospitalOsloNorway
| | - Lars Fjetland
- Stavanger Medical Imaging Laboratory (SMIL), Department of RadiologyStavanger University HospitalStavangerNorway,Department of Electrical and Computer EngineeringUniversity of StavangerStavangerNorway
| | - Kathinka D. Kurz
- Stavanger Medical Imaging Laboratory (SMIL), Department of RadiologyStavanger University HospitalStavangerNorway,Department of Electrical and Computer EngineeringUniversity of StavangerStavangerNorway
| | - Knut Olav Sandve
- Stavanger Medical Imaging Laboratory (SMIL), Department of RadiologyStavanger University HospitalStavangerNorway
| | - Martin W. Kurz
- Department of NeurologyStavanger University HospitalStavangerNorway,Neuroscience Research GroupStavanger University HospitalStavangerNorway,Department of Clinical ScienceUniversity of BergenBergenNorway
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8
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Pre-admission antithrombotic use is associated with 3-month mRS score after thrombectomy for acute ischemic stroke. J Thromb Thrombolysis 2022; 54:350-359. [PMID: 35864280 PMCID: PMC9302951 DOI: 10.1007/s11239-022-02680-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 10/24/2022]
Abstract
In patients who undergo thrombectomy for acute ischemic stroke, the relationship between pre-admission antithrombotic (anticoagulation or antiplatelet) use and both radiographic and functional outcome is not well understood. We sought to explore the relationship between pre-admission antithrombotic use in patients who underwent thrombectomy for acute ischemic stroke at two medical centers in New York City between December 2018 and November 2020. Analyses were performed using analysis of variance and Pearson's chi-squared tests. Of 234 patients in the analysis cohort, 65 (28%) were on anticoagulation, 64 (27%) were on antiplatelet, and 105 (45%) with no antithrombotic use pre-admission. 3-month Modified Rankin Scale (mRS) score of 3-6 was associated with pre-admission antithrombotic use (71% anticoagulation vs. 77% antiplatelet vs. 56% no antithrombotic, p = 0.04). There was no relationship between pre-admission antithrombotic use and Thrombolysis in Cerebral Iinfarction (TICI) score, post-procedure Alberta Stroke Program Early CT Score (ASPECTS) score, rate of hemorrhagic conversion, length of hospital admission, discharge NIH Stroke Scale (NIHSS), discharge mRS score, or mortality. When initial NIHSS score, post-procedure ASPECTS score, and age at admission were included in multivariate analysis, pre-admission antithrombotic use was still significantly associated with a 3-month mRS score of 3-6 (OR 2.36, 95% CI 1.03-5.54, p = 0.04). In this cohort of patients with acute ischemic stroke who underwent thrombectomy, pre-admission antithrombotic use was associated with 3-month mRS score, but no other measures of radiographic or functional outcome. Further research is needed on the relationship between use of specific anticoagulation or antiplatelet agents and outcome after acute ischemic stroke, but moreover, improve stroke prevention.
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9
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Chen JH, Hong CT, Chung CC, Kuan YC, Chan L. Safety and efficacy of endovascular thrombectomy in acute ischemic stroke treated with anticoagulants: a systematic review and meta-analysis. Thromb J 2022; 20:35. [PMID: 35729578 PMCID: PMC9210791 DOI: 10.1186/s12959-022-00394-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/12/2022] [Indexed: 11/24/2022] Open
Abstract
Background Endovascular thrombectomy (EVT) is an effective therapy in acute ischemic stroke (AIS) with large vessel occlusion, especially for those who are unsuitable for intravenous thrombolysis. However, the safety and efficacy of EVT in AIS patients who receiving oral anticoagulants (OACs) is unclear, especially for the risk of symptomatic intracranial hemorrhage (sICH). Methods Database of PubMed, Embase, and Cochrane Library were searched from Jan 1, 2000, through the final search date of Jun 2, 2021. Eligible studies for enrollment required outcomes reported for events of sICH, mortality, functional status, and successful reperfusion. Meta-analysis was conducted to compare the outcomes difference after EVT between AIS patients with or without OACs use. The primary safety outcome was sICH after EVT, and the primary efficacy outcome was functional status at 3 months. Results One thousand nine hundred forty studies were screened for eligibility and 15 of them were included in the meta-analysis. Compared the OACs group to control arm, vitamin K antagonists (VKAs) was associated with higher risk of sICH (OR 1.49, 95% CI 1.10–2.02) and mortality (OR 1.67, 95% CI 1.35–2.06). Poor functional outcomes were noted both in the VKAs and direct oral anticoagulants (DOACs) groups (OR 0.62, 95% CI 0.54–0.71 and OR 0.61, 95% CI 0.53–0.71, respectively). No differences in successful reperfusion were observed. Conclusions Comparing with DOACs, VKAs use was associated with a higher risk of sICH and mortality after EVT. Patients who did not receive OACs exhibited more favorable outcomes. The successful reperfusion did not differ between groups. However, results for mortality and functional outcomes have to be interpreted with caution since they are based on non-randomized data and unadjusted proportions. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00394-y.
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Affiliation(s)
- Jia-Hung Chen
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chien-Tai Hong
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chen-Chih Chung
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Chun Kuan
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Lung Chan
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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10
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Association Between Prior Anticoagulation and Thrombus Composition in Mechanical Thrombectomy Patients with Atrial Fibrillation. J Stroke Cerebrovasc Dis 2022; 31:106347. [PMID: 35158148 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106347] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/19/2021] [Accepted: 01/20/2022] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Anticoagulation (AC) is the main preventive strategy for ischemic stroke in atrial fibrillation (AF) patients. We aim to investigate the association of prior AC with thrombus composition and clinical outcome in AF patients with acute ischemic stroke (AIS). MATERIALS AND METHODS From January 2019 to December 2020, consecutive AIS patients with AF treated with mechanical thrombectomy (MT) in our center were included in this analysis. Retrieved thrombi were stained with hematoxylin and eosin (H&E) and Martius Scarlet blue (MSB). The relative fractions of red blood cell (RBC), white blood cell (WBC), fibrin, and platelet were quantitatively analyzed. Procedural and clinical outcomes were compared between patients with and without prior AC. RESULTS A total of 133 patients were enrolled in this study, with 39 in AC group and 94 in non-AC (NAC) group. Thrombi in AC group contained more fibrins (36% vs 20%, p<0.001), more platelets (36% vs 24%, p<0.001) and fewer RBCs (25% vs 54%, p<0.001). No difference was detected in terms of successful recanalization evaluated with modified Thrombolysis in Cerebral Infarction scale (mTICI 2b-3, 97% vs 86%, p=0.065), functional independence at 90 days with modified Rankin Score (mRS 0-2, 44% vs 33%, p=0.246). CONCLUSION Thrombi retrieved from AF patients with prior AC contained more fibrins, more platelets and fewer RBCs compared with those of NAC patients. A trend of higher successful reperfusion rate was observed in AC patients but failed to reach statistical significance.
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11
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Akbik F, Alawieh A, Dimisko L, Howard BM, Cawley CM, Tong FC, Nahab F, Samuels OB, Maier I, Feng W, Goyal N, Starke RM, Rai A, Fargen KM, Psychogios MN, Jabbour P, De Leacy R, Keyrouz SG, Dumont TM, Kan P, Liman J, Arthur AS, Wolfe SQ, Mocco J, Crosa RJ, Fox WC, Gory B, Spiotta AM, Grossberg JA. Bridging thrombolysis in atrial fibrillation stroke is associated with increased hemorrhagic complications without improved outcomes. J Neurointerv Surg 2021; 14:979-984. [PMID: 34819345 DOI: 10.1136/neurintsurg-2021-017954] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/27/2021] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Feras Akbik
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.,Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.,Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Laurie Dimisko
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Frank C Tong
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Fadi Nahab
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Owen B Samuels
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, Germany
| | - Wuwei Feng
- Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Nitin Goyal
- Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Robert M Starke
- Neurosurgery and Radiology, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Ansaar Rai
- Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Reade De Leacy
- Neurosurgery, The Mount Sinai Health System, New York, New York, USA
| | - Saleh G Keyrouz
- Department of Neurology, Washington University at St. Louis, St Louis, Missouri, USA
| | - Travis M Dumont
- Surgery, Division of Neurosurgery, Banner University of Arizona Medical Center, Tucson, Arizona, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Jan Liman
- Neurology, University Medical Center, Göttingen, Germany
| | - Adam S Arthur
- Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - J Mocco
- Neurosurgery, The Mount Sinai Health System, New York, New York, USA
| | | | - W Christopher Fox
- Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France.,INSERM, IADI, Université de Lorraine, Nancy, France
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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12
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Safety of Intravenous Thrombolysis for Acute Ischemic Stroke in Patients Taking Warfarin with Subtherapeutic INR. J Stroke Cerebrovasc Dis 2021; 30:105678. [PMID: 33640783 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105678] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/07/2021] [Accepted: 02/09/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Current guidelines allow the administration of intravenous recombinant tissue plasminogen activator (IV r-tPA) to warfarin-treated patients with acute ischemic stroke (AIS) who have an international normalized ratio (INR) of ≤1.7. However, concerns remain about the safety of using IV r-tPA in this situation due to a conceivable risk of symptomatic intracranial hemorrhage (sICH), lack of dedicated randomized controlled trials and the conflicts in the available data. We aimed to determine the risk of sICH in warfarin-treated patients with subtherapeutic INR who received IV r-tPA for AIS in our large volume comprehensive center. METHODS Patients who had received IV r-tPA for AIS in a 9.6-year period were retrospectively investigated (n = 834). Patients taking warfarin prior to presentation were identified (n = 55). One patient was excluded due to elevated INR beyond the acceptable range for IV r-tPA treatment. Because of the significant difference in the sample size (54 vs 779), warfarin group was matched with 54 non-warfarin patients adjusted for independent risk factors for sICH (age, admission NIHSS, history of diabetes). Good outcome was defined as mRS of 0-2 on discharge and sICH was defined as an ICH causing increase in NIHSS ≥4 or death. Warfarin-treated group was further dichotomized based on INR (1-1.3 vs 1.3-1.7) and safety and outcome measures were compared between resultant groups. RESULTS No significant difference was found between warfarin-treated and the non-warfarin groups in terms of chance of good outcome on discharge (27.8% in warfarin group vs 26.4% in non-warfarin group; p-value >0.05), or the rate of occurrence of sICH (3.7% in warfarin group vs 11.1% in non-warfarin group; p-value >0.05). Furthermore, rate of sICH (5.1% in patients with INR <1.3 versus 0.0% in patients with INR 1.3-1.7; p-value >0.05) or chance of good outcome on discharge (28.2% of patients with INR <1.3 versus 26.7% in patients with INR 1.3-1.7; p-value >0.05) were not found to be different after the warfarin-treated group was dichotomized. CONCLUSION Administration of IV r-tPA for AIS in warfarin-treated patients with subtherapeutic INR <1.7 does not increase the risk of sICH.
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13
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Küpper C, Feil K, Wollenweber FA, Tiedt S, Herzberg M, Dorn F, Liebig T, Dieterich M, Kellert L. Endovascular stroke treatment in orally anticoagulated patients: an analysis from the German Stroke Registry-Endovascular Treatment. J Neurol 2020; 268:1762-1769. [PMID: 33373024 PMCID: PMC8068620 DOI: 10.1007/s00415-020-10369-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 11/30/2022]
Abstract
Background Endovascular treatment (ET) in orally anticoagulated (OAC) patients has not been evaluated in randomized clinical trials and data regarding this issue are sparse. Methods We analyzed data from the German Stroke Registry-Endovascular Treatment (GSR-ET; NCT03356392, date of registration: 22 Nov 2017). The primary outcomes were successful reperfusion defined as modified thrombolysis in cerebral infarction (mTICI 2b-3), good outcome at 3 months (modified Rankin scale [mRS] 0–2 or back to baseline), and intracranial hemorrhage (ICH) on follow-up imaging at 24 h analyzed by unadjusted univariate and adjusted binary logistic regression analysis. Additionally, we analyzed mortality at 3 months with adjusted binary logistic regression analysis. Results Out of 6173 patients, there were 1306 (21.2%) OAC patients, 479 (7.8%) with vitamin K antagonists (VKA) and 827 (13.4%) with non-vitamin K antagonist oral anticoagulation (NOAC). The control group consisted of 4867 (78.8%) non-OAC patients. ET efficacy with the rates of mTICI 2b-3 was similar among the three groups (85.6%, 85.3% vs 84.3%, p = 0.93 and 1). On day 90, good outcome was less frequent in OAC patients (27.8%, 27.9% vs 39.5%, p < 0.005 and < 0.005). OAC status was not associated with ICH at 24 h (NOAC: odd’s ratio [OR] 0.89, 95% confidence interval [CI] 0.67–1.20; VKA: OR 1.04, CI 0.75–1.46). Binary logistic regression analysis revealed no influence of OAC status on good outcome at 3 months (NOAC: OR 1.25, CI 0.99–1.59; VKA: OR 1.18, CI 0.89–1.56) and mortality at 3 months (NOAC: OR 1.03, CI 0.81–1.30; VKA: OR 1.04, CI 0.78–1.1.37). Conclusions ET can be performed safely and successfully in LVO stroke patients treated with OAC. Clinical trial registration-URL http://www.clinicaltrials.gov. Unique identifier: NCT03356392. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-020-10369-6.
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Affiliation(s)
- Clemens Küpper
- Department of Neurology, Ludwig-Maximilians University, Marchioninistraße 15, 81377, Munich, Germany
| | - Katharina Feil
- Department of Neurology, Ludwig-Maximilians University, Marchioninistraße 15, 81377, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University, Munich, Germany.,Department of Neurology and Stroke, Eberhard-Karls University Tübingen, Universitätsklinikum Tübingen (UKT), Tübingen, Germany
| | | | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Moriz Herzberg
- Institute of Neuroradiology, Ludwig-Maximilians University, Munich, Germany
| | - Franziska Dorn
- Institute of Neuroradiology, Ludwig-Maximilians University, Munich, Germany.,Department of Neuroradiology, University of Bonn, Bonn, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, Ludwig-Maximilians University, Munich, Germany
| | - Marianne Dieterich
- Department of Neurology, Ludwig-Maximilians University, Marchioninistraße 15, 81377, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig-Maximilians University, Marchioninistraße 15, 81377, Munich, Germany.
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14
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Ramos-Araque ME, Chavarría-Miranda A, Gómez-Vicente B, López-Cancio Martínez E, Castañón Apilánez M, Castellanos M, López Fernández M, Tejada Meza H, Marta Moreno J, Tejada García J, Beltrán Rodríguez I, de la Riva P, Díez N, Arias Rivas S, Santamaría Cadavid M, Bravo Anguiano Y, Bártulos Iglesias M, Palacio Portilla EJ, Revilla García M, Timiraos Fernández JJ, Arenaza Basterrechea N, Maciñeiras Montero JL, Vicente Alba P, Julián Villaverde FJ, Pinedo Brochado A, Azkune I, Mar FM, Luna A, Arenillas JF. Oral Anticoagulation and Risk of Symptomatic Hemorrhagic Transformation in Stroke Patients Treated With Mechanical Thrombectomy: Data From the Nordictus Registry. Front Neurol 2020; 11:594251. [PMID: 33324333 PMCID: PMC7726434 DOI: 10.3389/fneur.2020.594251] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022] Open
Abstract
Introduction: We aimed to evaluate if prior oral anticoagulation (OAC) and its type determines a greater risk of symptomatic hemorrhagic transformation in patients with acute ischemic stroke (AIS) subjected to mechanical thrombectomy. Materials and Methods: Consecutive patients with AIS included in the prospective reperfusion registry NORDICTUS, a network of tertiary stroke centers in Northern Spain, from January 2017 to December 2019 were included. Prior use of oral anticoagulants, baseline variables, and international normalized ratio (INR) on admission were recorded. Symptomatic intracranial hemorrhage (sICH) was the primary outcome measure. Secondary outcome was the relation between INR and sICH, and we evaluated mortality and functional outcome at 3 months by modified Rankin scale. We compared patients with and without previous OAC and also considered the type of oral anticoagulants. Results: About 1.455 AIS patients were included, of whom 274 (19%) were on OAC, 193 (70%) on vitamin K antagonists (VKA), and 81 (30%) on direct oral anticoagulants (DOACs). Anticoagulated patients were older and had more comorbidities. Eighty-one (5.6%) developed sICH, which was more frequent in the VKA group, but not in DOAC group. OAC with VKA emerged as a predictor of sICH in a multivariate regression model (OR, 1.89 [95% CI, 1.01–3.51], p = 0.04) and was not related to INR level on admission. Prior VKA use was not associated with worse outcome in the multivariate regression model nor with mortality at 3 months. Conclusions: OAC with VKA, but not with DOACs, was an independent predictor of sICH after mechanical thrombectomy. This excess risk was associated neither with INR value by the time thrombectomy was performed, nor with a worse functional outcome or mortality at 3 months.
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Affiliation(s)
- María E Ramos-Araque
- Department of Neurology, Institute of Biomedical Research of Salamanca, Hospital Universitario de Salamanca, Salamanca, Spain.,Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Alba Chavarría-Miranda
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Beatriz Gómez-Vicente
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - María Castañón Apilánez
- Department of Neurology, Stroke Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Mar Castellanos
- A Coruña Biomedical Research Institute/A Coruña University Hospital, A Coruña, Spain
| | - María López Fernández
- A Coruña Biomedical Research Institute/A Coruña University Hospital, A Coruña, Spain
| | - Herbert Tejada Meza
- Department of Neurology, Stroke Unit, Hospital Universitario Miguel Servet, Zaragoza, Spain.,Department of Radiology, Neurointerventionism Unit, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Javier Marta Moreno
- Department of Neurology, Stroke Unit, Hospital Universitario Miguel Servet, Zaragoza, Spain.,Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, Spain
| | - Javier Tejada García
- Department of Neurology, Complejo Asistencial Universitario de León, León, Spain
| | | | | | - Noemi Díez
- Department of Neurology, Donostia University Hospital, San Sebastián, Spain
| | - Susana Arias Rivas
- Department of Neurology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - María Santamaría Cadavid
- Department of Neurology, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | | | | | | | - Marian Revilla García
- Department of Neurology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | | | | | - Pablo Vicente Alba
- Department of Neurology, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | | | | | - Itxaso Azkune
- Department of Neurology, Hospital Galdakao-Usansolo, Bizkaia, Spain
| | - Freijo M Mar
- Neurovascular Group, Neurology Department, Biocruces Research Health Institute, Cruces Hospital, Barakaldo, Spain
| | - Alain Luna
- Neurovascular Group, Neurology Department, Biocruces Research Health Institute, Cruces Hospital, Barakaldo, Spain
| | - Juan F Arenillas
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.,Clinical Neurosciences Research Group, Department of Medicine, University of Valladolid, Valladolid, Spain
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15
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Increased intracranial hemorrhage of mechanical thrombectomy in acute ischemic stroke patients with atrial fibrillation. J Thromb Thrombolysis 2020; 51:536-544. [PMID: 32918671 DOI: 10.1007/s11239-020-02269-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The impact of atrial fibrillation (AF) on outcomes of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is controversial, and with a paucity of evidence base. This study aimed to investigate the potential association between AF and outcomes after MT in AIS patients. A post-hoc analysis of a multi-center prospective clinical trial was conducted. Before and after propensity score matching (PSM), the clinical features were compared between patients with and without AF. Multivariable logistic regression and mediation analyses were performed to assess the relationship between AF and ICH. Of the total 245 patients, 123 patients were included in the AF group. After PSM, the AF group showed more retrieval attempts (P = 0.004), comparable favorable outcome (P = 0.493), and mortality (P = 0.362) at 90 days. Multivariate analysis revealed that AF was significantly associated with increased risk for ICH (OR 2.198; 95%CI 1.099-4.395; P = 0.026). INR and retrieval attempts were found to act as partial mediations. In the subgroup with lower INR, AF still had a significant association with ICH (OR 2.496; 95%CI 1.331-4.679; P = 0.004). In AIS patients undergoing MT, AF was associated with more retrieval attempts and higher risk of any ICH. Of note, the effect of AF on the increased risk of ICH was partly attributable to the adjusted anticoagulation status and more retrieval attempts. It is crucial to elaborately prevent ICH after thrombectomy for stroke patients with AF.
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Goldhoorn RJB, van de Graaf RA, van Rees JM, Lingsma HF, Dippel DWJ, Hinsenveld WH, Postma A, van den Wijngaard I, van Zwam WH, van Oostenbrugge RJ, Roozenbeek B. Endovascular Treatment for Acute Ischemic Stroke in Patients on Oral Anticoagulants: Results From the MR CLEAN Registry. Stroke 2020; 51:1781-1789. [PMID: 32390550 DOI: 10.1161/strokeaha.119.028675] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The use of oral anticoagulants (OAC) is considered a contra-indication for intravenous thrombolytics as acute treatment of ischemic stroke. However, little is known about the risks and benefits of endovascular treatment in patients on prior OAC. We aim to compare outcomes after endovascular treatment between patients with and without prior use of OAC. Methods- Data of patients with acute ischemic stroke caused by an intracranial anterior circulation occlusion, included in the nationwide, prospective, MR CLEAN Registry between March 2014 and November 2017, were analyzed. Outcomes of interest included symptomatic intracranial hemorrhage and functional outcome at 90 days (modified Rankin Scale score). Outcomes between groups were compared with (ordinal) logistic regression analyses, adjusted for prognostic factors. Results- Three thousand one hundred sixty-two patients were included in this study, of whom 502 (16%) used OAC. There was no significant difference in the occurrence of symptomatic intracranial hemorrhage between patients with and without prior OACs (5% versus 6%; adjusted odds ratio, 0.63 [95% CI, 0.38-1.06]). Patients on OACs had worse functional outcomes than patients without OACs (common odds ratio, 0.57 [95% CI, 0.47-0.66]). However, this observed difference in functional outcome disappeared after adjustment for prognostic factors (adjusted common odds ratio, 0.91 [95% CI, 0.74-1.13]). Conclusions- Prior OAC use in patients treated with endovascular treatment for ischemic stroke is not associated with an increased risk of symptomatic intracranial hemorrhage or worse functional outcome compared with no prior OAC use. Therefore, prior OAC use should not be a contra-indication for endovascular treatment.
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Affiliation(s)
- Robert-Jan B Goldhoorn
- From the Department of Neurology (R.-J.B.G., W.H.H., R.J. v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center
| | - Rob A van de Graaf
- Department of Neurology (R.A.v.d.G., J.M.v.R., D.W.J.D., B.R.), Erasmus MC, University Medical Center, Rotterdam.,Department of Radiology & Nuclear Medicine (R.A.v.d.G., B.R.), Erasmus MC, University Medical Center, Rotterdam
| | - Jan M van Rees
- Department of Neurology (R.A.v.d.G., J.M.v.R., D.W.J.D., B.R.), Erasmus MC, University Medical Center, Rotterdam
| | - Hester F Lingsma
- Department of Public Health (H.F.L.), Erasmus MC, University Medical Center, Rotterdam
| | - Diederik W J Dippel
- Department of Neurology (R.A.v.d.G., J.M.v.R., D.W.J.D., B.R.), Erasmus MC, University Medical Center, Rotterdam
| | - Wouter H Hinsenveld
- Department of Radiology (A.P., W.H.v.Z.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center
| | - Alida Postma
- Department of Radiology (A.P., W.H.v.Z.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center.,School for Mental Health and Sciences (Mhens), Maastricht University (A.P.)
| | - Ido van den Wijngaard
- Department of Neurology, Haaglanden Medical Center, The Hague (I.v.d.W.).,Department of Neurology, Leiden University Medical Center (I.v.d.W.)
| | - Wim H van Zwam
- From the Department of Neurology (R.-J.B.G., W.H.H., R.J. v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center.,Department of Radiology (A.P., W.H.v.Z.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center
| | - Robert J van Oostenbrugge
- From the Department of Neurology (R.-J.B.G., W.H.H., R.J. v.O.), Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center
| | - Bob Roozenbeek
- Department of Neurology (R.A.v.d.G., J.M.v.R., D.W.J.D., B.R.), Erasmus MC, University Medical Center, Rotterdam
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Safety of inter-hospital transfer of patients with acute ischemic stroke for evaluation of endovascular thrombectomy. Sci Rep 2020; 10:5655. [PMID: 32221353 PMCID: PMC7101346 DOI: 10.1038/s41598-020-62528-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/15/2020] [Indexed: 11/09/2022] Open
Abstract
Stroke networks facilitate access to endovascular treatment (EVT) for patients with ischemic stroke due to large vessel occlusion. In this study we aimed to determine the safety of inter-hospital transfer and included all patients with acute ischemic stroke who were transferred within our stroke network for evaluation of EVT between 06/2016 and 12/2018. Data were derived from our prospective EVT database and transfer protocols. We analyzed major complications and medical interventions associated with inter-hospital transfer. Among 615 transferred patients, 377 patients (61.3%) were transferred within our telestroke network and had transfer protocols available (median age 76 years [interquartile range, IQR 17], 190 [50.4%] male, median baseline NIHSS score 17 [IQR 8], 246 [65.3%] drip-and-ship i.v.-thrombolysis). No patient suffered from cardio-respiratory failure or required emergency intubation or cardiopulmonary resuscitation during the transfer. Among 343 patients who were not intubated prior departure, 35 patients (10.2%) required medical interventions during the transfer. The performance of medical interventions was associated with a lower EVT rate and higher mortality at three months. In conclusion, the transfer of acute stroke patients for evaluation of EVT was not associated with major complications and transfer-related medical interventions were required in a minority of patients.
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18
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Influence of oral anticoagulation on stroke severity and outcomes: A propensity score matching case-control study. J Neurol Sci 2020; 410:116685. [DOI: 10.1016/j.jns.2020.116685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 01/06/2020] [Accepted: 01/13/2020] [Indexed: 11/17/2022]
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Meinel TR, Kniepert JU, Seiffge DJ, Gralla J, Jung S, Auer E, Frey S, Goeldlin M, Mordasini P, Mosimann PJ, Nogueira RG, Haussen DC, Rodrigues GM, Uphaus T, L'Allinec V, Krajíčková D, Alonso A, Costalat V, Hajdu SD, Olivé-Gadea M, Maegerlein C, Pierot L, Schaafsma J, Suzuki K, Arnold M, Heldner MR, Fischer U, Kaesmacher J. Endovascular Stroke Treatment and Risk of Intracranial Hemorrhage in Anticoagulated Patients. Stroke 2020; 51:892-898. [PMID: 31992179 DOI: 10.1161/strokeaha.119.026606] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background and Purpose- We aimed to determine the safety and mortality after mechanical thrombectomy in patients taking vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Methods- In a multicenter observational cohort study, we used multiple logistic regression analysis to evaluate associations of symptomatic intracranial hemorrhage (sICH) with VKA or DOAC prescription before thrombectomy as compared with no anticoagulation. The primary outcomes were the rate of sICH and all-cause mortality at 90 days, incorporating sensitivity analysis regarding confirmed therapeutic anticoagulation. Additionally, we performed a systematic review and meta-analysis of literature on this topic. Results- Altogether, 1932 patients were included (VKA, n=222; DOAC, n=98; no anticoagulation, n=1612); median age, 74 years (interquartile range, 62-82); 49.6% women. VKA prescription was associated with increased odds for sICH and mortality (adjusted odds ratio [aOR], 2.55 [95% CI, 1.35-4.84] and 1.64 [95% CI, 1.09-2.47]) as compared with the control group, whereas no association with DOAC intake was observed (aOR, 0.98 [95% CI, 0.29-3.35] and 1.35 [95% CI, 0.72-2.53]). Sensitivity analyses considering only patients within the confirmed therapeutic anticoagulation range did not alter the findings. A study-level meta-analysis incorporating data from 7462 patients (855 VKAs, 318 DOACs, and 6289 controls) from 15 observational cohorts corroborated these observations, yielding an increased rate of sICH in VKA patients (aOR, 1.62 [95% CI, 1.22-2.17]) but not in DOAC patients (aOR, 1.03 [95% CI, 0.60-1.80]). Conclusions- Patients taking VKA have an increased risk of sICH and mortality after mechanical thrombectomy. The lower risk of sICH associated with DOAC may also be noticeable in the acute setting. Improved selection might be advisable in VKA-treated patients. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064. Systematic Review and Meta-Analysis: CRD42019127464.
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Affiliation(s)
- Thomas R Meinel
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Joachim U Kniepert
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - David J Seiffge
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Simon Jung
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Elias Auer
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Sebastién Frey
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Martina Goeldlin
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.).,University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Pascal J Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Raul G Nogueira
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Diogo C Haussen
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Gabriel M Rodrigues
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany, on behalf of the ENDOSTROKE Study Group (T.U.)
| | - Vincent L'Allinec
- Neuroradiology Department, Nantes University Hospital, France (V.L.)
| | - Dagmar Krajíčková
- Department of Neurology, Comprehensive Stroke Center, Faculty of Medicine in Hradec Králové, Charles University and University Hospital Hradec Králové, Czech Republic (D.K.)
| | - Angelika Alonso
- Department of Neurology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (A.A.)
| | | | - Steven D Hajdu
- Department of Radiology, CHUV Lausanne, Switzerland (S.D.H.)
| | - Marta Olivé-Gadea
- Department of Neurology, Hospital Universitario Vall d'Hebron, Barcelona, Spain (M.O.-G.)
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M.)
| | | | - Joanna Schaafsma
- Division of Neurology, University Health Network, University of Toronto, Canada (J.S.)
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan (K.S.)
| | - Marcel Arnold
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Mirjam R Heldner
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Urs Fischer
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.).,Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.).,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.)
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L'Allinec V, Sibon I, Mazighi M, Labreuche J, Kyheng M, Boissier E, Roy M, Gory B, Dargazanli C, Desal H, Lapergue B, Bourcier R. MT in anticoagulated patients. Neurology 2020; 94:e842-e850. [DOI: 10.1212/wnl.0000000000008873] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 08/29/2019] [Indexed: 11/15/2022] Open
Abstract
Mechanical thrombectomy (MT) is one of the main treatments for acute ischemic stroke (AIS) in patients on effective anticoagulation. The use of direct oral anticoagulants (DOA) has increased, given their efficacy and safety profile compared to vitamin K antagonists (VKA). We compared procedural and clinical outcomes of MT in patients on DOA and VKA treatment before stroke onset. We analyzed 2 groups from the Endovascular Treatment in Ischemic Stroke prospective registry: patients on DOA and patients on VKA treated by MT without thrombolysis. Generalized linear mixed models including center as random effect were used to compare angiographic (rates of reperfusion at end of procedure, number of passes >2, procedural complications) and clinical (favorable and excellent outcome, 90-day all-cause mortality, and hemorrhagic complications) outcomes according to anticoagulation subgroups. Comparisons were adjusted for prespecified confounders (age, admission NIH Stroke Scale score) as well as for meaningful baseline between-group differences. Among 221 patients included, more DOA-treated patients (n = 115, 52%) achieved successful (modified Thrombolysis in Cerebral Infarction score [mTICI] 2b/3) or near complete (mTICI 2c/3) reperfusion at the procedure end than did VKA-treated patients, with an adjusted odds ratio (OR) for DOA vs VKA of 3.27 (95% confidence interval [CI], 1.40–7.65) and 2.00 (95% CI, 1.08–3.73), respectively. DOA-treated patients had a lower 90-day mortality risk with an adjusted OR of 0.47 (95% CI, 0.24–0.89) and a better excellent outcome OR of 2.40 (1.10–5.27). There was no significant between-group difference in hemorrhagic or procedural complications. The study highlights the benefits of DOA compared to VKA. Regarding mortality, excellent outcomes, and recanalization rate, DOA appears to provide a favorable setting for MT treatment in AIS.
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21
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Martini M, Mocco J, Turk A, Siddiqui AH, Fiorella D, Hanel R, Woodward K, Rai A, Frei D, Delgado Almandoz JE, Kelly ME, Peeling L, Arthur AS, Baxter B, English J, Linfante I, De Leacy R. An international multicenter retrospective study to survey the landscape of thrombectomy in the treatment of anterior circulation acute ischemic stroke: outcomes with respect to age. J Neurointerv Surg 2019; 12:115-121. [DOI: 10.1136/neurintsurg-2019-015093] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 05/28/2019] [Accepted: 05/29/2019] [Indexed: 11/03/2022]
Abstract
BackgroundThrombectomy is an efficacious treatment for acute ischemic stroke (AIS). However, relatively few studies to date have specifically examined the impact and clinical implications of age on outcomes for thrombectomy in anterior AIS.ObjectiveTo provide a snapshot of patient metrics and outcomes with respect to age following thrombectomy for anterior AIS to supplement the current body of data for predictors of clinical outcomes in a real-world setting.MethodsData were collected for 20 consecutive patients with AIS treated with thrombectomy at 15 high-volume stroke centers across North America between 2015 and 2016. Patients with anterior occlusions were dichotomized based on whether they were older or younger than 80 years. Ordinal logistic regression analyzed how clinical variables impacted disability using 90-day modified Rankin Scale (mRS) scores.ResultsAdequate revascularization (TICI ≥2B) was achieved in 92.3% of patients aged <80 years with an average 1.7±0.1 passes taken with the primary technique and in 88.0% of patients aged ≥80 years with an average 1.7±0.2 passes. Despite similar baseline characteristics, mRS scores were significantly higher in older patients postoperatively and at 90 days after intervention. Age was a significant predictor of 90-day mRS across the study population.ConclusionThis analysis affirms age is a significant determinant of 90-day mRS scores following thrombectomy for large vessel anterior AIS. Further investigation into risks faced by elderly patients during thrombectomy may provide actionable information to help refine patient selection and improve outcomes.
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22
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Kadono Y, Nakamura H, Saito S, Nishida T, Takagaki M, Shigematsu T, Asai K, Murakami T, Todo K, Fujinaka T, Sakaguchi M, Toda K, Sawa Y, Kishima H. Endovascular treatment for large vessel occlusion stroke in patients with ventricular assist devices. J Neurointerv Surg 2019; 11:1205-1209. [DOI: 10.1136/neurintsurg-2018-014645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/11/2019] [Accepted: 04/18/2019] [Indexed: 11/04/2022]
Abstract
BackgroundEmbolic stroke with large vessel occlusion (LVO) is a major adverse event during ventricular assist device (VAD) support. In this study we aimed to clarify the efficacy of, and problems associated with, endovascular treatment (EVT) of LVO in patients with VAD support.MethodsWe retrospectively reviewed EVT for LVO in patients with VAD support between 2006 and 2017 at our institute and evaluated baseline characteristics, treatment variables, outcomes, and complications.ResultsThe study cohort comprised 12 consecutive patients (age 35.4±20.4 years), with 15 LVO events involving 20 arterial occlusions, who had undergone EVT. The median Alberta Stroke Program Early CT score was 10 and good collaterals were observed in 10 of 17 occluded middle cerebral artery areas. No study patients had received intravenous thrombolysis therapy. EVT was performed on 18 of the 20 occluded arteries and mechanical thrombectomy on 13 vessels. The successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2 b) rate was 67% in all EVTs and 85% with mechanical thrombectomy. Histological analysis showed fibrin-rich thrombi in four of five samples. Seven of 12 patients (58%) maintained their neurological function (modified Rankin Scale score ≤2 or equal to pre-stroke score) at 90 days. Periprocedural complications comprised two symptomatic intracranial hemorrhages and the 90-day mortality rate was 13%. Seven of 10 cardiac transplant candidates (70%) returned to the waiting list and three of them received transplants.ConclusionsEndovascular therapy for acute LVO stroke is feasible even in patients with VAD support.
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Clinical presentation, diagnostic findings and management of cerebral ischemic events in patients on treatment with non-vitamin K antagonist oral anticoagulants - A systematic review. PLoS One 2019; 14:e0213379. [PMID: 30925155 PMCID: PMC6440627 DOI: 10.1371/journal.pone.0213379] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/19/2019] [Indexed: 12/28/2022] Open
Abstract
Background Non-vitamin K antagonist oral anticoagulants (NOAC) are equally or potentially superior in terms of effectiveness in the prevention of ischemic stroke and carry a lower associated risk of intracranial hemorrhage compared to Vitamin K antagonists. Nevertheless, ischemic strokes also occur in patients who are being treated with NOAC. In those particular patients, knowledge about the underlying stroke etiology, clinical presentation, acute management, and complication rates is scarce. Objective Systematic literature review to provide a comprehensive clinical overview in terms of presentation, laboratory, imaging parameters and outcomes of patients suffering from acute cerebral ischemic events (i.e. TIA and acute ischemic stroke) while on treatment with a NOAC. Only if available, comparison to VKA is presented which was not the primary focus of this analysis. Data sources PubMed/MEDLINE, Scopus and EMBASE from January 1, 2006, to November 20, 2018. Study eligibility criteria 52 studies providing detailed information on a total of 12247 patients were included. We excluded case reports and case series with less than five patients. Study appraisal and synthesis method We systematically assessed study quality using a bias tool and pooled consistent data. Results Existing data indicates milder stroke severity and smaller infarct size of acute ischemic stroke on treatment with NOAC compared to stroke occurrence on Vitamin K antagonists (VKA). Established risk factors for ischemic events also play a role in stroke while on NOACs, albeit the underlying etiology remains poorly understood. Intravenous thrombolysis and endovascular therapy seem to be safe and effective, but patient selection for recanalization therapies is challenging. Limitations Limited quality of published data, duplicate cases, statistical issues of data pooling, possible incomplete retrieval of identified research and reporting bias might have limited our findings. Conclusions Acute ischemic events despite treatment with NOAC therapy are insufficiently investigated. Systematic review registration number PROSPERO: CRD42018074853.
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Safety and efficacy of mechanical thrombectomy with stent-retrievers in anticoagulated patients with anterior circulation stroke. Clin Radiol 2019; 74:165.e11-165.e16. [DOI: 10.1016/j.crad.2018.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 10/18/2018] [Indexed: 11/20/2022]
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Goyal N, Tsivgoulis G, Alexandrov AV, Arthur AS. Author response: Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion. Neurology 2018; 91:1116. [PMID: 30530560 DOI: 10.1212/wnl.0000000000006654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Zapata-Wainberg G, Masjuan J, Quintas S, Ximénez-Carrillo Á, García Pastor A, Martínez Zabaleta M, Cardona P, Freijo Guerrero MM, Llull L, Benavente Fernández L, Castellanos Rodrigo M, Egido J, Serena J, Vivancos J. The neurologist's approach to cerebral infarct and transient ischaemic attack in patients receiving anticoagulant treatment for non-valvular atrial fibrillation: ANITA-FA study. Eur J Neurol 2018; 26:230-237. [DOI: 10.1111/ene.13792] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 08/17/2018] [Indexed: 12/18/2022]
Affiliation(s)
- G. Zapata-Wainberg
- Neurology Department; Hospital Universitario de La Princesa; Instituto de Investigación Sanitaria Princesa; Madrid Spain
| | - J. Masjuan
- Neurology Department; Hospital Universitario Ramón y Cajal; Red INVICTUS PLUS; Departamento de Medicina; Universidad de Alcalá (IRYCIS); Madrid Spain
| | - S. Quintas
- Neurology Department; Hospital Universitario de La Princesa; Instituto de Investigación Sanitaria Princesa; Madrid Spain
| | - Á. Ximénez-Carrillo
- Neurology Department; Hospital Universitario de La Princesa; Instituto de Investigación Sanitaria Princesa; Madrid Spain
| | - A. García Pastor
- Neurology Department; Hospital General Universitario Gregorio Marañón; Madrid Spain
| | | | - P. Cardona
- Neurology Department; Hospital Universitari de Bellvitge; Barcelona Spain
| | | | - L. Llull
- Neurology Department; Hospital Universitari Clinic; Barcelona Spain
| | | | | | - J. Egido
- Hospital Clínico Universitario San Carlos; Madrid Spain
| | - J. Serena
- Neurology Department; Hospital Universitario Dr Josep Trueta; Girona Spain
| | - J. Vivancos
- Neurology Department; Hospital Universitario de La Princesa; Red INVICTUS PLUS; Instituto de Investigación Sanitaria La Princesa; Madrid Spain
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