Rebello Letícia C, Haussen Diogo C, Belagaje Samir, Anderson Aaron, Frankel Michael, Nogueira Raul G
From the Emory University School of Medicine/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA.
Stroke. 2015 Dec;46(12):3536-9. doi: 10.1161/STROKEAHA.115.011285. Epub 2015 Oct 15.
Oral anticoagulation (OAC) plays a major role in atrial fibrillation stroke prevention but represents a contraindication to intravenous tissue-type plasminogen activator. Intra-arterial therapy remains a potential reperfusion strategy in these patients; however, supporting data are scarce.
Retrospective analysis of prospectively collected consecutive intra-arterial therapies from October 2010 to March 2015 comparing OAC (vitamin-K antagonists and novel oral anticoagulants) versus normal hemostasis versus intravenous tissue-type plasminogen activator patients. Primary safety end point is parenchymal hematoma. Secondary safety end point is 90-day mortality. Efficacy end points are successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b-3) and good outcome (90-day modified Rankin Scale score of 0-2). Logistic regression for predictors of parenchymal hematoma was performed.
A total of 604 patients were qualified for the study. Baseline and outcomes variables were overall similar for vitamin-K antagonists (n=29) and novel oral anticoagulants (n=17) patients. When compared with normal hemostasis (n=265) and intravenous tissue-type plasminogen activator (n=297), OAC (n=46) patients were older and had more comorbidities. There were no statistically significant differences in the rates of parenchymal hematoma (8% versus 5%; P=0.42), 90-day modified Rankin Scale score of 0 to 2 (30% versus 40%; P=0.26), and 90-day mortality (32% versus 26%; P=0.46) among OAC and normal hemostasis patients. Similarly, there were no significant differences between OAC and intravenous tissue-type plasminogen activator patients in terms of parenchymal hematoma (8% versus 4%; P=0.16), 90-day modified Rankin Scale score of 0 to 2 (30% versus 43%; P=0.13), and 90-day mortality (32% versus 22%; P=0.18). The use of OAC was not associated with the occurrence of parenchymal hematoma on multivariate logistic regression analysis.
Intra-arterial therapy seems to be safe in patients taking OACs; however, our study showed a nonsignificant increase in hemorrhage and mortality with a nonsignificant decrease in good outcomes in comparison with non-OAC patients. Although these nominal differences may have been related to older age and more comorbidities in the OAC group, larger studies are needed to confirm our findings given our limited sample size.
口服抗凝药（OAC）在预防房颤卒中方面发挥着重要作用，但却是静脉注射组织型纤溶酶原激活剂的禁忌证。动脉内治疗仍是这些患者潜在的再灌注策略；然而，支持数据较少。
对2010年10月至2015年3月前瞻性收集的连续动脉内治疗进行回顾性分析，比较使用OAC（维生素K拮抗剂和新型口服抗凝药）的患者、凝血功能正常的患者以及静脉注射组织型纤溶酶原激活剂的患者。主要安全终点是脑实质血肿。次要安全终点是90天死亡率。疗效终点是成功再灌注（改良脑梗死溶栓分级，2b - 3级）和良好预后（90天改良Rankin量表评分为0 - 2分）。对脑实质血肿的预测因素进行逻辑回归分析。
共有604例患者符合研究条件。维生素K拮抗剂组（n = 29）和新型口服抗凝药组（n = 17）患者的基线和结局变量总体相似。与凝血功能正常组（n = 265）和静脉注射组织型纤溶酶原激活剂组（n = 297）相比，使用OAC的患者（n = 46）年龄更大，合并症更多。在OAC组和凝血功能正常组患者中，脑实质血肿发生率（8%对5%；P = 0.42）、90天改良Rankin量表评分为0至2分的比例（30%对40%；P = 0.26）以及90天死亡率（32%对26%；P = 0.46）差异均无统计学意义。同样，在OAC组和静脉注射组织型纤溶酶原激活剂组患者之间，脑实质血肿发生率（8%对4%；P = 0.16）、90天改良Rankin量表评分为0至2分的比例（30%对43%；P = 0.13）以及90天死亡率（32%对22%；P = 0.18）差异也无统计学意义。多因素逻辑回归分析显示，使用OAC与脑实质血肿的发生无关。
对于服用OAC的患者，动脉内治疗似乎是安全的；然而，我们的研究表明，与未使用OAC的患者相比，出血和死亡率虽无显著增加，但良好预后却有不显著的下降。尽管这些名义上的差异可能与OAC组患者年龄较大和合并症较多有关，但鉴于我们的样本量有限，需要更大规模的研究来证实我们的发现。
