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

Longting Lin; Christopher Blair; James Fu; Dennis Cordato; Cecilia Cappelen-Smith; Andrew Cheung; Nathan W Manning; Jason Wenderoth; Chushuang Chen; Andrew Bivard; Kenneth Butcher; Timothy J Kleinig; Philip Choi; Christopher R Levi; Mark Parsons; INSPIRE study group

doi:10.1136/jnis-2022-019560

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

J Neurointerv Surg. 2023 Dec 21;15(e3):e433-e437. doi: 10.1136/jnis-2022-019560.

Authors

Longting Lin^{1

2}, Christopher Blair^{1

2}, James Fu¹, Dennis Cordato^{1

2

3}, Cecilia Cappelen-Smith^{1

2

3}, Andrew Cheung^{1

4

5

6}, Nathan W Manning^{1

4

5

6}, Jason Wenderoth^{1

4

5

6}, Chushuang Chen⁷, Andrew Bivard^{2

8}, Kenneth Butcher⁵, Timothy J Kleinig⁹, Philip Choi¹⁰, Christopher R Levi⁷, Mark Parsons^{11

2

3}; INSPIRE study group

Collaborators

INSPIRE study group:
Christopher R Levi, Neil J Spratt, Carlos Garcia-Esperon, Ferdinand Miteff, Philip M Choi, Timothy Kleining, Billy O'Brien, Kenneth Butcher, Jianhong Yang, Congguo Yin, Peng Wang, Yu Geng, Xuezhi Yang, Qi Fang, Yi Sui, Wenhuo Chen, Xin Cheng, Qiang Dong, Gang Li

Affiliations

¹ South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia.
² Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.
³ Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.
⁴ Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia.
⁵ Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia.
⁶ Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.
⁷ Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia.
⁸ Melbourne Brain Centre, University of Melbourne, Melbourne, Victoria, Australia.
⁹ Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
¹⁰ Department of Neurology, Eastern Health Box Hill, Melbourne, Victoria, Australia.
¹¹ South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia mark.parsons@unsw.edu.au.

PMID: 36944493
DOI: 10.1136/jnis-2022-019560

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.

Keywords: Stroke; Thrombectomy; Thrombolysis.

Publication types

Multicenter Study

MeSH terms

Anticoagulants
Atrial Fibrillation* / complications
Atrial Fibrillation* / drug therapy
Atrial Fibrillation* / surgery
Brain Ischemia* / diagnostic imaging
Brain Ischemia* / drug therapy
Brain Ischemia* / surgery
Cerebral Hemorrhage / etiology
Endovascular Procedures* / methods
Humans
Retrospective Studies
Stroke* / diagnostic imaging
Stroke* / drug therapy
Stroke* / surgery
Thrombectomy / methods
Thrombolytic Therapy / methods
Treatment Outcome

Substances

Anticoagulants