Kurowski Donna, Jonczak Karin, Shah Qaisar, Yaghi Shadi, Marshall Randolph S, Ahmad Haroon, McKinney James, Torres Jose, Ishida Koto, Cucchiara Brett
Department of Neurology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania.
Department of Neurology, Abington Memorial Hospital, Abington, Pennsylvania.
J Stroke Cerebrovasc Dis. 2017 May;26(5):1104-1109. doi: 10.1016/j.jstrokecerebrovasdis.2016.12.027. Epub 2017 Jan 16.
Intravenous (IV) tissue plasminogen activator (tPA) is contraindicated in therapeutically anti-coagulated patients. Such patients may be considered for endovascular intervention. However, there are limited data on its safety.
We performed a multicenter retrospective study of patients undergoing endovascular intervention for acute ischemic stroke while on therapeutic anticoagulation. We compared the observed rate of National Institute of Neurological Disorders and Stroke defined symptomatic intracerebral hemorrhage (sICH) with risk-adjusted historical control rates of sICH after IV tPA using weighted averages of the hemorrhage after thrombolysis (HAT) and Multicenter Stroke Survey (MSS) prediction scores. We also performed a metaanalysis of studies assessing risk of sICH with endovascular intervention in patients on anticoagulation.
Of 94 cases, mean age was 73 years and median National Institutes of Health Stroke Scale was 19. Anticoagulation consisted of warfarin (n = 51), dabigatran (n = 6), rivaroxaban (n = 13), apixaban (n = 1), IV heparin (n = 19), low molecular weight heparin (n = 3), and combined warfarin and IV heparin (n = 3). sICH was seen in 7 patients (7%, 95% confidence interval 4-15), all on warfarin. Predicted sICH rates for the cohort based on HAT and MSS scoring were 12% and 7%, respectively. Meta-analysis of 6 studies showed no significant difference in sICH between patients undergoing endovascular intervention on anticoagulation and comparator groups.
Endovascular intervention in subjects on therapeutic anticoagulation appears reasonably safe, with a sICH rate similar to patients not on anticoagulation receiving IV tPA.
静脉注射组织型纤溶酶原激活剂（tPA）在接受治疗性抗凝的患者中是禁忌的。这类患者可考虑进行血管内介入治疗。然而，关于其安全性的数据有限。
我们对接受治疗性抗凝的急性缺血性卒中患者进行血管内介入治疗的情况进行了一项多中心回顾性研究。我们使用溶栓后出血（HAT）和多中心卒中调查（MSS）预测评分的加权平均值，将观察到的美国国立神经疾病和卒中研究所定义的症状性颅内出血（sICH）发生率与静脉注射tPA后经风险调整的sICH历史对照发生率进行了比较。我们还对评估接受抗凝治疗的患者进行血管内介入治疗时sICH风险的研究进行了荟萃分析。
94例患者中，平均年龄为73岁，美国国立卫生研究院卒中量表中位数为19。抗凝治疗包括华法林（n = 51）、达比加群（n = 6）、利伐沙班（n = 13）、阿哌沙班（n = 1）、静脉注射肝素（n = 19）、低分子肝素（n = 3）以及华法林与静脉注射肝素联合使用（n = 3）。7例患者（7%，95%置信区间4 - 15）出现sICH，均使用华法林治疗。基于HAT和MSS评分，该队列预测的sICH发生率分别为12%和7%。对6项研究的荟萃分析表明，接受抗凝治疗的患者进行血管内介入治疗与对照组在sICH方面无显著差异。
接受治疗性抗凝的患者进行血管内介入治疗似乎相当安全，sICH发生率与未接受抗凝治疗但接受静脉注射tPA的患者相似。
