Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.
Department of Neurology, Emory University, Atlanta, Georgia, USA.
J Neurointerv Surg. 2022 Oct;14(10):979-984. doi: 10.1136/neurintsurg-2021-017954. Epub 2021 Nov 24.
Atrial fibrillation (AF) associated ischemic stroke is associated with worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Conversely, AF is not associated with hemorrhagic complications or functional outcomes in patients undergoing mechanical thrombectomy (MT). This differential effect of MT and IVT in AF associated stroke raises the question of whether bridging thrombolysis increases hemorrhagic complications in AF patients undergoing MT.
This international cohort study of 22 comprehensive stroke centers analyzed patients with large vessel occlusion (LVO) undergoing MT between June 1, 2015 and December 31, 2020. Patients were divided into four groups based on comorbid AF and IVT exposure. Baseline patient characteristics, complications, and outcomes were reported and compared.
6461 patients underwent MT for LVO. 2311 (35.8%) patients had comorbid AF. In non-AF patients, bridging therapy improved the odds of good 90 day functional outcomes (adjusted OR (aOR) 1.29, 95% CI 1.03 to 1.60, p=0.025) and did not increase hemorrhagic complications. In AF patients, bridging therapy led to significant increases in symptomatic intracranial hemorrhage and parenchymal hematoma type 2 (aOR 1.66, 1.07 to 2.57, p=0.024) without any benefit in 90 day functional outcomes. Similar findings were noted in a separate propensity score analysis.
In this large thrombectomy registry, AF patients exposed to IVT before MT had increased hemorrhagic complications without improved functional outcomes, in contrast with non-AF patients. Prospective trials are warranted to assess whether AF patients represent a subgroup of LVO patients who may benefit from a direct to thrombectomy approach at thrombectomy capable centers.
房颤（AF）相关缺血性卒中与更差的功能结局、再通效果较差以及静脉溶栓（IVT）后出血性并发症发生率增加相关。相反，在接受机械取栓（MT）的患者中，AF 与出血性并发症或功能结局无关。MT 和 IVT 在 AF 相关卒中中的这种不同作用提出了一个问题，即在接受 MT 的 AF 患者中，桥接溶栓是否会增加出血性并发症。
这项对 22 个综合卒中中心的国际队列研究分析了 2015 年 6 月 1 日至 2020 年 12 月 31 日期间接受 MT 治疗的大血管闭塞（LVO）患者。根据合并 AF 和 IVT 暴露情况，将患者分为四组。报告并比较了基线患者特征、并发症和结局。
6461 例患者接受 MT 治疗 LVO。2311（35.8%）例患者合并 AF。在非 AF 患者中，桥接治疗改善了 90 天良好功能结局的可能性（调整后的 OR（aOR）1.29，95%CI 1.03 至 1.60，p=0.025），且不会增加出血性并发症。在 AF 患者中，桥接治疗导致症状性颅内出血和实质血肿 2 型显著增加（aOR 1.66，1.07 至 2.57，p=0.024），而 90 天功能结局没有任何改善。在单独的倾向评分分析中也观察到了类似的发现。
在这项大型取栓登记研究中，与非 AF 患者相比，接受 MT 前接受 IVT 的 AF 患者出血性并发症增加，而功能结局无改善。需要进行前瞻性试验来评估 AF 患者是否代表 LVO 患者的亚组，他们可能受益于在有取栓能力的中心直接进行取栓的方法。
