Abstract 1122‐000084: Does Intravenous Thrombolysis Promote Delayed Reperfusion After Incomplete Mechanical Thrombectomy?

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Adnan Mujanovic ◽  
Christoph Kammer ◽  
Christoph C Kurmann ◽  
Lorenz Grunder ◽  
Morin Beyeler ◽  
...  
Keyword(s):  
Perfusion Imaging ◽  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Considerable Proportion ◽  
Time Interval ◽  
Start Time ◽  
Vessel Occlusion ◽  
Stroke Registry

Introduction : The value of intravenous thrombolysis (IVT) in patients eligible for mechanical thrombectomy (MT) remains unclear. We hypothesized that pre‐treatment with and/or ongoing IVT may facilitate reperfusion of distal vessel occlusion after incomplete MT. We evaluated this potential association using follow‐up perfusion imaging. Methods : Retrospective observational analysis of our institution`s stroke registry included patients with incomplete reperfusion after MT, admitted between February 1, 2015 and December 8, 2020. Delayed reperfusion (DR) was defined as the absence of a persistent perfusion deficit on contrast‐enhanced perfusion imaging ⁓24h±12h after the intervention. The association between baseline parameters and the occurrence of DR was evaluated using a logistic regression analyses. To account for possible time‐dependent associations of IVT with DR, additional stratification sets were made based on different time windows between IVT start time and final angiography runs. Results : Among the 378 included patients (median age 73.5, 50.8% female), DR occurred in 226 (59.8%). Atrial fibrillation (aOR 2.53 [95% CI 1.34 ‐ 4.90]), eTICI score (aOR 3.79 [95% CI 2.71 ‐ 5.48] per TICI grade increase), and intervention‐to‐follow‐up time (aOR 1.08 [95% CI 1.04 ‐ 1.13] per hour delay) were associated with DR. Dichotomized IVT strata showed no association with DR (aOR 0.75 [95% CI 0.42 ‐ 1.33]), whereas shorter intervals between IVT start and end of the procedure showed a borderline significant association with DR (OR 2.24 [95% CI 0.98 ‐ 5.43, and OR 2.07 [95% 1.06 – 4.31], for 80 and 100 minutes respectively). Patients with DR had higher rates of functional independence (modified Rankin scale 0–2 at 90 days, DR: 63.3% vs PPD: 38.8%; p<0.01) and longer survival time (at 3 years, DR: 69.2% vs PPD: 45.8%; p = 0.001). Conclusions : There is weak evidence that IVT may favor DR after incomplete MT if the time interval between IVT administration and end of the procedure is short. In general, perfusion follow‐up imaging may constitute a suitable surrogate parameter for evaluating medical rescue strategies after incomplete MT, because a considerable proportion of patients do not experience DR, and there seems to be a close correlation with clinical outcomes.

Antiplatelet pretreatment and outcomes following mechanical thrombectomy for emergent large vessel occlusion strokes

2017 ◽  
Vol 10 (9) ◽  
pp. 828-833 ◽  
Author(s):  
Abhi Pandhi ◽  
Georgios Tsivgoulis ◽  
Rashi Krishnan ◽  
Muhammad F Ishfaq ◽  
Savdeep Singh ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Large Vessel ◽  
Vessel Occlusion ◽  
Safety And Efficacy ◽  
Logistic Regression Models ◽  
Scale Scores ◽  
Stroke Center ◽  
Few Data

BackgroundFew data are available regarding the safety and efficacy of antiplatelet (APT) pretreatment in acute ischemic stroke (AIS) patients with emergent large vessel occlusions (ELVO) treated with mechanical thrombectomy (MT). We sought to evaluate the association of APT pretreatment with safety and efficacy outcomes following MT for ELVO.MethodsConsecutive ELVO patients treated with MT during a 4-year period in a tertiary stroke center were evaluated. The following outcomes were documented using standard definitions: symptomatic intracranial hemorrhage (sICH), successful recanalization (SR; modified TICI score 2b/3), mortality, and functional independence (modified Rankin Scale scores of 0–2).ResultsThe study population included 217 patients with ELVO (mean age 62±14 years, 50% men, median NIH Stroke Scale score 16). APT pretreatment was documented in 71 cases (33%). Patients with APT pretreatment had higher SR rates (77% vs 61%; P=0.013). The two groups did not differ in terms of sICH (6% vs 7%), 3-month mortality (25% vs 26%), and 3-month functional independence (50% vs 48%). Pretreatment with APT was independently associated with increased likelihood of SR (OR 2.18, 95% CI1.01 to 4.73; P=0.048) on multivariable logistic regression models adjusting for potential confounders. A significant interaction (P=0.014) of intravenous thrombolysis (IVT) pretreatment on the association of pre-hospital antiplatelet use with SR was detected. APT pretreatment was associated with SR (OR 2.74, 95% CI 1.15 to 6.54; P=0.024) in patients treated with combination therapy (IVT and MT) but not in those treated with direct MT (OR 1.78, 95% CI 0.63 to 5.03; P=0.276).ConclusionAPT pretreatment does not increase the risk of sICH and may independently improve the odds of SR in patients with ELVO treated with MT. The former association appears to be modified by IVT.

Intravenous thrombolysis pretreatment and other predictors of infarct in a new previously unaffected territory (INT) in ELVO strokes treated with mechanical thrombectomy

2019 ◽  
Vol 12 (2) ◽  
pp. 142-147 ◽  
Author(s):  
Nitin Goyal ◽  
Georgios Tsivgoulis ◽  
Jason J Chang ◽  
Konark Malhotra ◽  
Juan Goyanes ◽  
...  
Keyword(s):  
Regression Models ◽  
Mechanical Thrombectomy ◽  
Independent Predictor ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Posterior Circulation ◽  
National Institutes Of Health ◽  
Special Focus ◽  
Vessel Occlusion ◽  
Logistic Regression Models

IntroductionOne uncommon complication of mechanical thrombectomy (MT) is an infarct in a new previously unaffected territory (infarct in new territory (INT)).ObjectiveTo evaluate the predictors of INT with special focus on intravenous thrombolysis(IVT)pretreatmentbefore MT.MethodsConsecutive patients with emergent large vessel occlusion (ELVO) treated with MT during a 5-year period were evaluated. INT was defined using standardized methodology proposed by ESCAPE investigators. The predictors of INT and its impact on outcomes were investigated.ResultsA total of 419 consecutive patients with ELVO received MT (mean age 64±15 years, 50% men, median baseline National Institutes of Health Stroke Scale score 16 points (IQR 11–20), 69% pretreated with IVT). The incidence of INT was lower in patients treated with combination therapy (IVTandMT) than in patients treated with MT alone, respectively (10% vs 20%; p=0.011). The INT group had more patients with posterior circulation occlusions than the group without INT (28% vs 10%, respectively; p<0.001). The rates of 3-month functional independence were lower in patients with INT (30% vs 50%; p=0.007). IVT pretreatment was not independently related to INT (OR=0.75; 95% CI 0.32 to 1.76), and INT did not emerge as an independent predictor of 3-month functional independence (OR=0.69; 95% CI 0.29 to 1.62) on multivariable logistic regression models. Location of posterior circulation occlusion was independently associated with a higher odds of INT (OR=3.33; 95% CI 1.43 to 7.69; p=0.005).ConclusionsIVT pretreatment is not independently associated with a lower likelihood of INT in patients with ELVO treated with MT. Patients with ELVO with posterior circulation occlusion are more likely to have INT after MT.

Assessment of computed tomography perfusion software in predicting spatial location and volume of infarct in acute ischemic stroke patients: a comparison of Sphere, Vitrea, and RAPID

2020 ◽  
pp. neurintsurg-2020-015966 ◽  
Author(s):  
Ryan A Rava ◽  
Kenneth V Snyder ◽  
Maxim Mokin ◽  
Muhammad Waqas ◽  
Xiaoliang Zhang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Conservative Treatment ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Ct Perfusion ◽  
Intravenous Thrombolysis ◽  
Spatial Location ◽  
Endovascular Intervention ◽  
Vessel Occlusion

BackgroundCT perfusion (CTP) infarct and penumbra estimations determine the eligibility of patients with acute ischemic stroke (AIS) for endovascular intervention. This study aimed to determine volumetric and spatial agreement of predicted RAPID, Vitrea, and Sphere CTP infarct with follow-up fluid attenuation inversion recovery (FLAIR) MRI infarct.Methods108 consecutive patients with AIS and large vessel occlusion were included in the study between April 2019 and January 2020 . Patients were divided into two groups: endovascular intervention (n=58) and conservative treatment (n=50). Intervention patients were treated with mechanical thrombectomy and achieved successful reperfusion (Thrombolysis in Cerebral Infarction 2b/2 c/3) while patients in the conservative treatment group did not receive mechanical thrombectomy or intravenous thrombolysis. Intervention and conservative treatment patients were included to assess infarct and penumbra estimations, respectively. It was assumed that in all patients treated conservatively, penumbra converted to infarct. CTP infarct and penumbra volumes were segmented from RAPID, Vitrea, and Sphere to assess volumetric and spatial agreement with follow-up FLAIR MRI.ResultsMean infarct differences (95% CIs) between each CTP software and FLAIR MRI for each cohort were: intervention cohort: RAPID=9.0±7.7 mL, Sphere=−0.2±8.7 mL, Vitrea=−7.9±8.9 mL; conservative treatment cohort: RAPID=−31.9±21.6 mL, Sphere=−26.8±17.4 mL, Vitrea=−15.3±13.7 mL. Overlap and Dice coefficients for predicted infarct were (overlap, Dice): intervention cohort: RAPID=(0.57, 0.44), Sphere=(0.68, 0.60), Vitrea=(0.70, 0.60); conservative treatment cohort: RAPID=(0.71, 0.56), Sphere=(0.73, 0.60), Vitrea=(0.72, 0.64).ConclusionsSphere proved the most accurate in patients who had intervention infarct assessment as Vitrea and RAPID overestimated and underestimated infarct, respectively. Vitrea proved the most accurate in penumbra assessment for patients treated conservatively although all software overestimated penumbra.

Impact of pretreatment with intravenous thrombolysis on reperfusion status in acute strokes treated with mechanical thrombectomy

2019 ◽  
Vol 11 (11) ◽  
pp. 1073-1079 ◽  
Author(s):  
Nitin Goyal ◽  
Georgios Tsivgoulis ◽  
Abhi Pandhi ◽  
Konark Malhotra ◽  
Rashi Krishnan ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Tertiary Care ◽  
Intravenous Thrombolysis ◽  
High Volume ◽  
Functional Independence ◽  
Median Number ◽  
Vessel Occlusion ◽  
Multivariable Analyses ◽  
Stroke Center ◽  
The Impact

IntroductionWe sought to evaluate the impact of pretreatment with intravenous thrombolysis (IVT) on the rate and speed of successful reperfusion (SR) in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT) in a high-volume tertiary care stroke center.MethodsConsecutive patients with ELVO treated with MT were evaluated. Outcomes were compared between patients who underwent combined IVT and MT (IVT+MT) and those treated with direct MT (dMT). The elapsed time between groin puncture to beginning of reperfusion (GPTBRT) and the numbers of device passes required to achieve SR were also documented.ResultsA total of 287 and 132 patients were treated with IVT+MT and dMT, respectively. The IVT+MT group had higher SR (73.8% vs 62.9%; p=0.023) and 3-month functional independence (modified Rankin Scale score 0–2;51.6% vs 38.2%; p=0.008) rates. The median GPTBRT was shorter in the IVT+MT group (48 (IQR 33–70) vs 70 (IQR 44–98) min; p<0.001). Among patients who achieved SR (n=292), the median number of required device passes was lower in the IVT+MT subgroup (1 (IQR 1–1) vs 2 (IQR 1–2); p<0.001), while the rate of patients requiring ≤2 device passes was higher (98% vs 77%; p<0.001). IVT+MT was independently related to higher odds of SR (OR 1.64; 95% CI 1.03 to 2.61; p=0.036) and shorter GPTBRT (unstandardized linear regression coefficient −20.39; 95% CI −27.56 to –13.22; p<0.001) on multivariable analyses adjusting for potential confounders. Among patients with SR, IVT+MT was independently associated with a higher likelihood of ≤2 device passes (OR 14.63; 95% CI 4.46 to 48.00; p<0.001).ConclusionsIVT pretreatment appears to increase the rates of SR and shortens the duration of the endovascular procedure by requiring fewer device passes in patients with ELVO treated with MT.

scholarly journals Extended Window for Stroke Thrombectomy

2019 ◽  
Vol 10 (02) ◽  
pp. 294-300 ◽  
Author(s):  
Brian Snelling ◽  
David J. Mccarthy ◽  
Stephanie Chen ◽  
Samir Sur ◽  
Omar Elwardany ◽  
...  
Keyword(s):  
Perfusion Imaging ◽  
Randomized Clinical Trials ◽  
Standard Treatment ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Functional Independence ◽  
Endovascular Management ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Symptomatic Intracranial Hemorrhage

ABSTRACT Objective: Mechanical thrombectomy is the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke (AIS) up to 6 h after onset. Recent trials have demonstrated a benefit for wake-up strokes and patients beyond 6 h. Methods: A systematic literature review was conducted for multicenter randomized clinical trials (RCTs) investigating endovascular stroke treatment using perfusion imaging to identify patients that may benefit from mechanical thrombectomy for AIS beyond 6 h of onset. Random effects meta-analysis was used to analyze the following outcomes: 90-day functional independence rates with modified Rankin Scale (mRS ≤2), 90-day mortality, and symptomatic intracranial hemorrhage (sICH) rates. Further stratification was carried out by age and presentation. Results: Two multicenter RCT’s were included as follows: DAWN and DEFUSE-3. Pooled 90-day functional independence rates favored endovascular management (odds ratio [OR] 5.01; P < 0.00001). Subgroup analysis demonstrated continued 90-day functional independence benefit for endovascular management regardless of age (≥80 years, OR 5.65, P = 0.01; ≤80 years, OR 4.92, P < 0.00001). When stratified for the manner of stroke discovery, 90-day functional independence rates favored endovascular management for wake-up strokes (OR 8.74, P < 0.00001) and known-time onset strokes (OR 5.08, 95% confidence interval [CI] 2.04–12.65, P = 0.0005), although no benefit was observed for unwitnessed strokes (OR 1.64, 95% CI 0.17–16.04, P = 0.67). No difference observed in 90-day mortality rates (OR 0.71; P = 0.14) or in SICH rates (OR 1.67; P = 0.29). Conclusions: This meta-analysis reinforces that endovascular management is superior to standard medical management alone for the treatment of AIS due to LVO beyond 6 h of onset in patients with perfusion-imaging selection.

scholarly journals More Retrieval Attempts are Associated with Poorer Functional Outcome After Unsuccessful Thrombectomy

2021 ◽  
Author(s):  
F. Flottmann ◽  
N. van Horn ◽  
M. E. Maros ◽  
H. Leischner ◽  
M. Bechstein ◽  
...  
Keyword(s):  
Propensity Score ◽  
Clinical Outcome ◽  
Propensity Score Matching ◽  
Mechanical Thrombectomy ◽  
Harmful Effect ◽  
Functional Independence ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Stroke Registry ◽  
The Impact

Abstract Purpose In mechanical thrombectomy, it has been hypothesized that multiple retrieval attempts might the improve reperfusion rate but not the clinical outcome. In order to assess a potential harmful effect of a mechanical thrombectomy on patient outcome, the number of retrieval attempts was analyzed. Only patients with a thrombolysis in cerebral infarction (TICI) score of 0 were reviewed to exclude the impact of eventual successful reperfusion on the mechanical hazardousness of repeated retrievals. Methods In this study 6635 patients who underwent endovascular thrombectomy (EVT) for acute large vessel occlusion (LVO) from the prospectively administered multicenter German Stroke Registry were screened. Insufficient reperfusion was defined as no reperfusion (TICI score of 0), whereas a primary outcome was defined as functional independence (modified Rankin scale [mRS] 0–2 at day 90). Propensity score matching and multivariable logistic regressions were then performed to adjust for confounders. Results A total of 377 patients (7.8%) had a final TICI score of 0 and were included in the study. After propensity score matching functional independence was found to be significantly more frequent in patients who underwent ≤ 2 retrieval attempts (14%), compared to patients with > 2 retrieval attempts (3.9%, OR 0.29, 95% CI 0.07–0.73, p = 0.009). After adjusting for age, sex, admission NIHSS score, and location of occlusion, more than two retrieval attempts remained significantly associated with lower odds of functional independence at 90 days (OR 0.2, 95% CI 0.07–0.52, p = 0.002). Conclusion In patients with failure of reperfusion, more than two retrieval attempts were associated with a worse clinical outcome, therefore indicating a possible harmful effect of multiple retrieval attempts.

scholarly journals Breaking the breach in Latin America: A pilot study of mechanical thrombectomy in the public healthcare system in Chile

2020 ◽  
pp. 159101992095640
Author(s):  
Rodrigo Rivera ◽  
Cristian Amudio ◽  
Enzo Brunetti ◽  
Pascual Catalan ◽  
Juan Gabriel Sordo ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Functional Independence ◽  
Public Healthcare ◽  
Vessel Occlusion ◽  
The Public ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Symptomatic Intracranial Hemorrhage ◽  
Stroke Center

Background Mechanical Thrombectomy (MT) is the standard of care for treatment of large vessel occlusion stroke. Until the beginning of 2020 MT was not funded nor widely implemented at the public healthcare level in Chile. Objective To describe the results of a pilot program created to provide access to public MT in Santiago - Chile. Methods Analysis from a prospectively collected database of MT cases performed between September 2017 and September 2019 in one center. A stroke network was developed with a single MT capable stroke center and five primary stroke centers. The primary efficacy endpoint was the rate of functional independence (mRS 0-2) at 90 days. Successful reperfusion was defined as 2 b-3 according to the thrombolysis in cerebral infarction scale. Safety outcomes include the rates of symptomatic intracranial hemorrhage and 90-day mortality. Results A total of 100 patients were treated over the study period. Their mean age was 62.8 ± 11.8 years and median baseline National Institute of Health Stroke Scale (NIHSS) measurement was 17. Seventy-seven percent of the patients received intra venous thrombolysis. Successful reperfusion was achieved in 95% of the cases. NIHSS at 24 hours showed a median drop of 7 points from baseline (p < 0.00001) and 50% of the follow-up patients were functionally independent at 90 days. Symptomatic Intracerebral hemorrhage occurred in 5% of the patients and 90-day all case mortality was 11%. Conclusions We demonstrated the feasibility of a publicly funded MT program in Chile, with similar results as other international randomized control trials.

Predictors of malignant brain edema after mechanical thrombectomy for acute ischemic stroke

2019 ◽  
Vol 11 (10) ◽  
pp. 994-998 ◽  
Author(s):  
Xianjun Huang ◽  
Qian Yang ◽  
Xiaolei Shi ◽  
Xiangjun Xu ◽  
Liang Ge ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Brain Edema ◽  
Functional Outcomes ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Large Vessel Occlusion ◽  
Midline Shift ◽  
Anterior Circulation ◽  
Vessel Occlusion

BackgroundMalignant brain edema (MBE) is a devastating complication in ischemic stroke. Data on MBE in patients who have had mechanical thrombectomy (MT) are relatively scarce.ObjectiveTo investigate the incidence, predictors, and clinical outcomes of MBE in patients after MT.MethodsWe included 130 consecutive patients after MT caused by anterior circulation large vessel occlusion stroke, treated with MT. MBE was defined as a midline shift of ≥5 mm on the follow-up imaging within 72 hours after MT. Characteristics of patients at admission and details of treatment were collected. The 90-day modified Rankin scale score was used as a measure of functional outcomes.ResultsOf the 130 patients (age, 68.6±10.9 years; male, 50%), 35 (26.9%) patients developed MBE. The patients with MBE had a lower rate of functional independence (OR=7.831; 95% CI 1.731 to 35.427; p=0.008) and significantly higher mortality at 90 days (OR=7.958; 95% CI 2.274 to 27.848; p=0.001) than patients without MBE. In 104 (80%) patients with successful recanalization (modified Thrombolysis in Cerebral Infarction score of 2b–3), 24 (23.1%) patients exhibited MBE. After adjustment for confounding, ICA occlusion (OR=3.746; 95% CI 1.169 to 12.006; p=0.026) and worse collateral score (grade 1 vs grade 0: OR=0.727; 95% CI 0.192 to 2.753; p=0.638; grade 2 vs grade 0: OR=0.130; 95% CI 0.021 to 0.819; p=0.030) were significantly associated with the development of MBE, despite successful recanalization.ConclusionsMBE after MT is not uncommon and was related to poor functional outcomes. Localization of a vessel occlusion and collateral status may play a role in the development of MBE.

scholarly journals Perfusion Imaging to Select Patients with Large Ischemic Core for Mechanical Thrombectomy

2020 ◽  
Vol 22 (2) ◽  
pp. 225-233 ◽  
Author(s):  
Basile Kerleroux ◽  
Kevin Janot ◽  
Cyril Dargazanli ◽  
Dimitri Daly-Eraya ◽  
Wagih Ben-Hassen ◽  
...  
Keyword(s):  
Perfusion Imaging ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Primary Outcome Measure ◽  
Favorable Outcome ◽  
Vessel Occlusion ◽  
Logistic Regression Models ◽  
Ischemic Core ◽  
Core Volume ◽  
Large Infarct

Background and Purpose Patients with acute ischemic stroke, proximal vessel occlusion and a large ischemic core at presentation are commonly not considered for mechanical thrombectomy (MT). We tested the hypothesis that in patients with baseline large infarct cores, identification of remaining penumbral tissue using perfusion imaging would translate to better outcomes after MT.<br/>Methods This was a multicenter, retrospective, core lab adjudicated, cohort study of adult patients with proximal vessel occlusion, a large ischemic core volume (diffusion weighted imaging volume ≥70 mL), with pre-treatment magnetic resonance imaging perfusion, treated with MT (2015 to 2018) or medical care alone (controls; before 2015). Primary outcome measure was 3-month favorable outcome (defined as a modified Rankin Scale of 0–3). Core perfusion mismatch ratio (CPMR) was defined as the volume of critically hypo-perfused tissue (Tmax >6 seconds) divided by the core volume. Multivariable logistic regression models were used to determine factors that were independently associated with clinical outcomes. Outputs are displayed as adjusted odds ratio (aOR) and 95% confidence interval (CI).<br/>Results A total of 172 patients were included (MT n=130; Control n=42; mean age 69.0±15.4 years; 36% females). Mean core-volume and CPMR were 102.3±36.7 and 1.8±0.7 mL, respectively. As hypothesized, receiving MT was associated with increased probability of favorable outcome and functional independence, as CPMR increased, a difference becoming statistically significant above a mismatch-ratio of 1.72. Similarly, receiving MT was also associated with favorable outcome in the subgroup of 74 patients with CPMR >1.7 (aOR, 8.12; 95% CI, 1.24 to 53.11; P=0.028). Overall (prior to stratification by CPMR) 73 (42.4%) patients had a favorable outcome at 3 months, with no difference amongst groups.<br/>Conclusions In patients currently deemed ineligible for MT due to large infarct ischemic cores at baseline, CPMR identifies a subgroup strongly benefiting from MT. Prospective studies are warranted.

Safety of Endovascular Thrombectomy for Acute Ischaemic Stroke in Anticoagulated Patients Ineligible for Intravenous Thrombolysis

2018 ◽  
Vol 46 (5-6) ◽  
pp. 193-199 ◽  
Author(s):  
John W.P. Wong ◽  
Leonid Churilov ◽  
Richard Dowling ◽  
Peter Mitchell ◽  
Steven Bush ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Mechanical Thrombectomy ◽  
Oral Anticoagulants ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Endovascular Thrombectomy ◽  
Intravenous Tissue Plasminogen Activator ◽  
Number Of Patients ◽  
Anticoagulated Patients

Background/Aim: Endovascular thrombectomy may be performed in anticoagulated patients taking vitamin-K antagonists (VKA) or direct-acting oral anticoagulants (DOAC) in whom the use of intravenous tissue plasminogen activator (tPA) is contraindicated. We aimed to investigate the efficacy and safety of mechanical thrombectomy specifically in anticoagulated patients ineligible for thrombolysis. Methods: We performed a retrospective analysis of a prospectively collected database of consecutive ischaemic stroke patients undergoing mechanical thrombectomy from January 2008 to June 2017. Patients receiving any dose of intravenous or intra-arterial thrombolysis were excluded. Patients taking oral anticoagulants (VKAs or DOACs) were compared with non-anticoagulated patients. Outcomes compared between groups included the rate of intracerebral haemorrhage (ICH) on follow-up imaging (ICHany), symptomatic ICH, functional independence at 90 days (modified Rankin scale score, 0–2), mortality, and post-treatment recanalization (Thrombolysis in Cerebral Infarction score ≥2b). Results: In all, 102 patients undergoing mechanical thrombectomy without prior thrombolysis were included in the study. Sixty-six (64.7%) patients were not anticoagulated, 23 (22.5%) patients were taking VKAs, and 13 (12.7%) patients were taking DOACs. There were no significant differences in the rate of ICHany (11.1 vs. 13.6%, p = 0.93) or sICH (2.8 vs. 1.5%, p = 0.14) in anticoagulated patients compared to non-anticoagulated patients. No cases of sICH were observed among patients taking DOACs. After 90 days of follow-up, the rates of functional independence (50.0 vs. 43.1%) and mortality (27.8 vs. 25.8%) were also similar between the anticoagulation and the non-anticoagulation groups. Conclusion: Mechanical thrombectomy appears to be safe and effective in anticoagulated patients ineligible for thrombolysis, with observed haemorrhage rates similar to those of patients not on anticoagulant therapy. However, further multicentre prospective studies are needed, due to the rising number of patients on warfarin and DOACs worldwide.

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