Bridging thrombolysis in atrial fibrillation stroke is associated with increased hemorrhagic complications without improved outcomes

Akbik, Feras; Alawieh, Ali; Dimisko, Laurie; Howard, Brian M.; Cawley, C. Michael; Tong, Frank; Nahab, Fadi; Samuels, Owen; Maier, Ilko; Feng, Wuwei; Goyal, Nitin; Starke, Robert M.; Rai, Ansaar; Fargen, Kyle M; Psychogios, Marios; Jabbour, Pascal; Leacy, Reade De; Keyrouz, Saleh G.; Dumont, Travis M.; Kan, Peter; Liman, Jan; Arthur, Adam S; Wolfe, Stacey Quintero; Mocco, J; Crosa, Roberto; Fox, W. Christopher; Gory, Benjamin; Spiotta, Alejandro M; Grossberg, Jonathan A; Thrombectomy, Stroke

doi:10.1136/neurintsurg-2021-017954

Cited by 15 publications

(21 citation statements)

References 35 publications

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“…Those mechanisms support our results in explaining the more frequent haemorrhagic transformation and poor outcomes among patients with AF after AIS [32,33]. Our finding in line with recently thrombectomy registry study indicated that AF patients exposed to intravenous thrombolysis before mechanical thrombectomy had increased haemorrhagic complications without improved functional outcomes, in contrast with non-AF patients [34].…”

Section: Discussionsupporting

confidence: 91%

Baseline brain imaging signs in patients with ischaemic stroke by the presence of atrial fibrillation: the ENCHANTED trial

et al. 2023

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Background We aimed to assess the association of atrial fibrillation (AF) on outcomes in a post hoc analysis of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study) and how this association is modified by baseline imaging features. Methods Inverse probability of treatment weight was used to remove baseline imbalances between those with and without AF. The primary outcome was the modified Rankin Scale (mRS) scores at 90 days. Secondary outcomes were symptomatic intracerebral haemorrhage (sICH), early neurological deterioration or death within 24 h, and death at 90 days. The logistic regression model was used to determine the associations. Results Of the 3285 patients included in this analysis, 636 (19%) had AF at baseline. Compared with non-AF, AF was not significantly associated with an unfavourable shift of mRS (odds ratio 1.09; 95% confidence interval, 0.96–1.24), but with sICH (2.82; 1.78-4.48; IST-3 criteria), early neurological deterioration or death within 24 h (1.31; 1.01-1.70), and death (1.42; 1.12-1.79). Among patients with acute ischaemic signs (presence, extent, swelling and attenuation of acute lesions), AF was associated with the increased risk of all the poor outcomes (all P < 0.04 for interaction). Conclusions We found AF increased risk of sICH, early neurological deterioration or death and death, but not unfavourable functional recovery at day 90 after thrombolysis in patients with AIS. The presence of acute ischaemic brain imaging signs at stroke presentation could be used to improve risk stratification in the presence of AF. Trial registration The trial is registered at ClinicalTrials.gov (NCT01422616).

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Section: Discussionsupporting

confidence: 91%

Baseline brain imaging signs in patients with ischaemic stroke by the presence of atrial fibrillation: the ENCHANTED trial

et al. 2023

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“…Atrial fibrillation has been shown to modify the effect of reperfusion therapies on outcomes. In recent analysis of the STAR registry, bridging therapy was associated with an increased risk of hemorrhagic complications in patients with atrial fibrillation 19. A subsequent multicentric observational study failed to demonstrate similar findings 20.…”

Section: Discussionmentioning

confidence: 99%

Effect of intravenous thrombolysis before endovascular therapy on outcomes in patients with large core infarct

Anadani

Almallouhi

Maier³

et al. 2023

J NeuroIntervent Surg

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BackgroundThe safety and efficacy of bridging therapy with intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in patients with large core infarct has not been sufficiently studied. In this study, we compared the efficacy and safety outcomes between patients who received IVT+MT and those treated with MT alone.MethodsThis is a retrospective analysis of the Stroke Thrombectomy Aneurysm Registry (STAR). Patients with Alberta Stroke Program Early CT Score (ASPECTS) ≤5 treated with MT were included in this study. Patients were divided into two groups based on pre-treatment IVT (IVT, no IVT). Propensity score matched analysis were used to compare outcomes between groups.ResultsA total of 398 patients were included; 113 pairs were generated using propensity score matching analyses. Baseline characteristics were well balanced in the matched cohort. The rate of any intracerebral hemorrhage (ICH) was similar between groups in both the full cohort (41.4% vs 42.3%, P=0.85) and matched cohort (38.55% vs 42.1%, P=0.593). Similarly, the rate of significant ICH was similar between the groups (full cohort: 13.1% vs 16.9%, P=0.306; matched cohort: 15.6% vs 18.95, P=0.52). There was no difference in favorable outcome (90-day modified Rankin Scale 0–2) or successful reperfusion between groups. In an adjusted analysis, IVT was not associated with any of the outcomes.ConclusionPretreatment IVT was not associated with an increased risk of hemorrhage in patients with large core infarct treated with MT. Future studies are needed to assess the safety and efficacy of bridging therapy in patients with large core infarct.

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“…Nie et al reported better results with BT in patients with basilar artery occlusions [ 40 ]. In two studies, the efficacy of BT was evaluated in patients with a cardioembolic stroke, showing no differences and a worse functional outcome in the BT group, respectively [ 41 , 42 ]. There is also no consensus regarding tandem carotid occlusions, with some data supporting a better prognosis with BT and others showing a higher mortality in this group [ 32 , 38 ].…”

Section: Discussionmentioning

confidence: 99%

Direct Mechanical Thrombectomy vs. Bridging Therapy in Stroke Patients in A “Stroke Belt” Region of Southern Europe

Toro-Pérez

Amaya-Pascasio

Guevara-Sánchez

et al. 2023

JPM

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The aim of this 4-year observational study is to analyze the outcomes of stroke patients treated with direct mechanical thrombectomy (dMT) compared to bridging therapy (BT) (intravenous thrombolysis [IVT] + BT) based on 3-month outcomes, in real clinical practice in the "Stroke Belt" of Southern Europe. In total, 300 patients were included (41.3% dMT and 58.6% BT). The frequency of direct referral to the stroke center was similar in the dMT and BT group, whereas the time from onset to groin was longer in the BT group (median 210 [IQR 160–303] vs. 399 [IQR 225–675], p = 0.001). Successful recanalization (TICI 2b-3) and hemorrhagic transformation were similar in both groups. The BT group more frequently showed excellent outcomes at 3 months (32.4% vs. 15.4%, p = 0.004). Multivariate analysis showed that BT was independently associated with excellent outcomes (OR 2.7. 95% CI,1.2–5.9, p = 0.02) and lower mortality (OR 0.36. 95% CI 0.16–0.82, p = 015). Conclusions: Compared with dMT, BT was associated with excellent functional outcomes and lower 3-month mortality in this real-world clinical practice study conducted in a region belonging to the “Stroke Belt” of Southern Europe. Given the disparity of results on the benefit of BT in the current evidence, it is of vital importance to analyze the convenience of its use in each health area.

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Bridging thrombolysis in atrial fibrillation stroke is associated with increased hemorrhagic complications without improved outcomes

Cited by 15 publications

References 35 publications

Baseline brain imaging signs in patients with ischaemic stroke by the presence of atrial fibrillation: the ENCHANTED trial

Baseline brain imaging signs in patients with ischaemic stroke by the presence of atrial fibrillation: the ENCHANTED trial

Effect of intravenous thrombolysis before endovascular therapy on outcomes in patients with large core infarct

Direct Mechanical Thrombectomy vs. Bridging Therapy in Stroke Patients in A “Stroke Belt” Region of Southern Europe

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