From the Departments of Neurosurgery (J.J.V., M.K.) and Neurology (D.S., J.P.), Helsinki University Hospital and University of Helsinki, Finland.
Neurology. 2021 Nov 2;97(18):e1790-e1798. doi: 10.1212/WNL.0000000000012771. Epub 2021 Oct 6.
Unruptured intracranial aneurysms (UIAs) are considered to be a relative contraindication for IV thrombolysis (IVT) in acute ischemic stroke (AIS). Currently, however, data are limited on the risk of UIA rupture after IVT. Our objective was to assess whether IVT for AIS can lead to a UIA rupture and intracranial hemorrhages (ICHs) in patients with unruptured UIAs.
This was a prospective cohort study of consecutive patients treated in a comprehensive stroke center between 2005 and 2019. We assessed radiology reports and records at the Finnish Care Register for Health Care to identify patients with UIAs among all patients with AIS treated with IVT at the center. We analyzed patient angiograms for aneurysm characteristics and other brain imaging studies for ICHs after IVT. The main outcome was in-hospital ICHs attributable to a UIA rupture after IVT. Secondary outcomes were in-hospital symptomatic ICHs (European-Australian Cooperative Acute Stroke Study [ECASS-2] criteria, i.e., NIH Stroke Scale score increase ≥4 points) and any in-hospital ICHs.
A total of 3,953 patients were treated with IVT during the 15-year study period. One hundred thirty-two (3.3%) of the 3,953 patients with AIS had a total of 155 UIAs (141 saccular and 14 fusiform). The mean diameter of UIAs was 4.7 ± 3.8 mm, with 18.7% being ≥7 mm and 9.7% ≥10 mm in diameter. None of the 141 saccular UIAs ruptured after IVT. Three patients (2.3%, 95% confidence interval [CI] 0.6%-5.8%) with large fusiform basilar artery UIAs had a fatal rupture at 27 hours, 43 hours, and 19 days after IVT. All 3 were administered anticoagulation treatments after IVT, and anticoagulation took effect during the UIA rupture. Any ICHs and symptomatic ICHs were detected in 18.9% (95% CI 12.9%-26.2%) and 8.3% (95% CI 4.4%-13.8%) of all patients with AIS, respectively.
IVT appears to be safe in patients with AIS with saccular UIAs, including larges UIAs (≥10 mm). Anticoagulation after AIS in patients with large fusiform posterior circulation UIAs may increase the risk of aneurysm rupture.
未破裂颅内动脉瘤（UIAs）被认为是急性缺血性卒中（AIS）患者静脉溶栓（IVT）的相对禁忌证。然而，目前关于 IVT 后 UIAs 破裂风险的数据有限。我们的目的是评估 AIS 患者接受 IVT 是否会导致未破裂 UIAs 破裂和颅内出血（ICH）。
这是一项连续患者的前瞻性队列研究，在 2005 年至 2019 年间在综合卒中中心进行。我们评估了芬兰医疗保健登记处的放射学报告和记录，以确定在该中心接受 IVT 治疗的所有 AIS 患者中的 UIAs 患者。我们分析了患者的血管造影以评估动脉瘤特征，以及其他脑成像研究以评估 IVT 后的 ICH。主要结局是 IVT 后 UIA 破裂导致的住院期间 ICH。次要结局是住院期间症状性 ICH（欧洲-澳大利亚急性卒中研究 [ECASS-2] 标准，即 NIH 卒中量表评分增加≥4 分）和任何住院期间 ICH。
在 15 年的研究期间，共有 3953 例患者接受了 IVT 治疗。在 3953 例 AIS 患者中，有 132 例（3.3%）共 155 个 UIAs（141 个囊状和 14 个梭形）。UIAs 的平均直径为 4.7±3.8mm，其中 18.7%的直径≥7mm，9.7%的直径≥10mm。IVT 后没有一个囊状 UIAs 破裂。3 例（2.3%，95%置信区间 [CI] 0.6%-5.8%）大梭形基底动脉 UIAs 在 IVT 后 27 小时、43 小时和 19 天时发生致命性破裂。这 3 例患者在 IVT 后均接受抗凝治疗，并且在 UIA 破裂期间抗凝起效。所有 AIS 患者中分别有 18.9%（95%CI 12.9%-26.2%）和 8.3%（95%CI 4.4%-13.8%）发生任何 ICH 和症状性 ICH。
IVT 似乎在 AIS 伴有囊状 UIAs（包括大 UIAs[≥10mm]）的患者中是安全的。AIS 后在大梭形后循环 UIAs 患者中进行抗凝治疗可能会增加动脉瘤破裂的风险。
