Differential effect of mechanical thrombectomy and intravenous thrombolysis in atrial fibrillation associated stroke

Abstract

BackgroundAtrial fibrillation (AF) associated ischemic stroke has worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Limited data exist about the effect of AF on procedural and clinical outcomes after mechanical thrombectomy (MT).ObjectiveTo determine whether recanalization efficacy, procedural speed, and clinical outcomes differ in AF associated stroke treated with MT.MethodsWe performed a retrospective cohort study of the Stroke Thrombectomy and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4169 patients who underwent MT for an anterior circulation stroke, 1517 (36.4 %) of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared.ResultsAF predicted faster procedural times, fewer passes, and higher rates of first pass success on multivariate analysis (p<0.01). AF had no effect on intracranial hemorrhage (aOR 0.69, 95% CI 0.43 to 1.12) or 90-day functional outcomes (aOR 1.17, 95% CI 0.91 to 1.50) after MT, although patients with AF were less likely to receive IVT (46% vs 54%, p<0.0001).ConclusionsIn patients treated with MT, comorbid AF is associated with faster procedural time, fewer passes, and increased rates of first pass success without increased risk of intracranial hemorrhage or worse functional outcomes. These results are in contrast to the increased hemorrhage rates and worse functional outcomes observed in AF associated stroke treated with supportive care and or IVT. These data suggest that MT negates the AF penalty in ischemic stroke.

Clinical and Non-Clinical Determinants of the Effect of Mechanical Thrombectomy and Post-Stroke Functional Status of Patients in Short and Long-Term Follow-Up

“…To date, several independent factors have been identified by some authors which reportedly worsen the functional status of patients undergoing MT for stroke. These include older age, low ASPECTS scores, and high NIHSS scores [12][13][14]17,18]. In terms of the importance of age and neurological status, we have confirmed the reports of other authors; we have also gained more experience concerning the influence of a patient's clinical profile on the outcome of endovascular therapy and their post-stroke functional status in the acute period of stroke.…”

“…Therefore, attempts are being made to identify the parameters to determine the outcome of endovascular therapy in acute stroke patients. The most common findings are age, the patients' neurological status during the ultra-acute stage of stroke, and the ASPECTS score [12][13][14]. Atrial fibrillation, diabetes, previous exposure to anticoagulation, the morphotic parameters of blood, and inflammatory parameters all have a conflicting status in several studies [12,[15][16][17].…”

“…The most common findings are age, the patients' neurological status during the ultra-acute stage of stroke, and the ASPECTS score [12][13][14]. Atrial fibrillation, diabetes, previous exposure to anticoagulation, the morphotic parameters of blood, and inflammatory parameters all have a conflicting status in several studies [12,[15][16][17]. If factors affecting the safety and efficacy of MT could be identified, that results would influence the selection of patients for the procedure and thus optimize the efficacy of endovascular procedures in stroke.…”

Bleeding risk in patients with cardiac disease from ischaemic stroke reperfusion therapy: an update

“… 15 This result is further confirmed by another study performed using the multicentre Stroke Thrombectomy and Aneurysm Registry, which concluded that the presence of premorbid AF in patients who achieved good recanalisation post ET did not impact sICH rates (aOR 0.69, 95% CI 0.43 to 1.12). 16 A large 2015 multicentre retrospective analysis searched for risk factors for ICH after ET and found that AF was associated with a higher risk of ICH, but this result did not persist after adjusting for vascular risk factors. Notably, there was also no significant difference in successful recanalisation rates between those who developed sICH versus those who did not.…”

Inhouse Bridging Thrombolysis Is Associated With Improved Functional Outcome in Patients With Large Vessel Occlusion Stroke: Findings From the German Stroke Registry

“…Most importantly, there were around 5% more cardio-embolic strokes and 2.6% less macroangiopathic strokes in the EVT alone group. While IVT might have facilitating effects in both stroke etiologies, cardio-embolic thrombi removal by EVT in the majority of cases is faster and easier compared with often hard, calcified, and plaque-associated thrombi and emboli ( 24 , 25 ). One could assume equal effects of IVT in both groups, while time to reperfusion has been shorter in the EVT alone group because of technically easier clot removals in this group requiring less passes and aspirations.…”