But those who can be given recombinant tPA along with mechanical thrombectomy may fare best of all, observational study suggests.
Outcomes of mechanical thrombectomy appear to be similar for both anticoagulated and nonanticoagulated patients with acute ischemic stroke, according to an analysis published online March 30, 2018, ahead of print in the Journal of NeuroInterventional Surgery.
Yet neither group did as well as patients not on anticoagulants at the time of stroke who received intravenous recombinant tPA on top of mechanical thrombectomy; this subset had lower risks of intracranial hemorrhage (ICH) and 3-month mortality
The study authors, led by Vincent L’Allinec, MD (University of Nantes Hospital, France), point out that one of the main contraindications to use of recombinant tPA for the treatment of acute ischemic stroke is previous effective anticoagulation treatment with heparin, vitamin K antagonists, or non-vitamin K antagonist oral anticoagulants. The main reason for this is the increased risk of ICH.
It remains unclear whether this ICH risk of carried by anticoagulation is similarly prohibitive among patients treated with mechanical thrombectomy. Large trials evaluating the safety and efficacy of mechanical thrombectomy for acute ischemic stroke either excluded or underrepresented anticoagulated patients.
The investigators analyzed data on 333 patients from two prospective registries who underwent mechanical thrombectomy: 44 (12%) were anticoagulated, 105 (31%) were not anticoagulated and did not receive recombinant tPA, and 188 (57%) were not anticoagulated and were treated with recombinant tPA.
Patients who were anticoagulated were significantly older, more often had atrial fibrillation, and had a higher ASPECTS compared with nonanticoagulated patients who did and did not receive recombinant tPA, respectively.
Multivariate analysis revealed that the anticoagulated patients who underwent mechanical thrombectomy had a lower risk of radiological ICH but a higher risk of death at 3 months than did the nonanticoagulated patients treated with recombinant tPA and mechanical thrombectomy. There were no significant differences in outcomes between the anticoagulated and the nonanticoagulated patients who did not receive recombinant tPA.
Outcomes Compared With Anticoagulated Patients: OR 95% CI
|
|
Nonanticoagulated (n = 105) |
P Value |
Nonanticoagulated + tPA (n = 188) |
P Value |
|
Radiological ICH |
1.47 (0.49-4.34) |
0.48 |
2.77 (1.01-7.61) |
0.05 |
|
Symptomatic ICH |
0.94 (0.11-8.17) |
0.77 |
0.59 (0.09-3.97) |
0.77 |
|
90-Day mRS ≥ 2 |
0.43 (0.14-1.32) |
0.07 |
0.29 (0.10-0.87) |
0.07 |
|
3-Month Mortality |
0.35 (0.11-1.13) |
0.08 |
0.26 (0.09-0.76) |
0.05 |
The authors conclude that mechanical thrombectomy “seems as safe and efficient” regardless of whether patients are or aren’t anticoagulated. “As suggested by the guidelines,” they write, “[the intervention] should be considered to treat [anticoagulated patients] with large vessel occlusion.”
Beyond the potentially increased 3-month mortality among anticoagulated patients, patients in this group “probably need specific postprocedural management in order to prevent an unfavorable outcome due to poorer baseline conditions,” L'Allinec and colleagues conclude, adding, “Larger prospective studies are needed to confirm our findings.”
Source:
L'Allinec V, Ernst M, Sevin-Allouet M, et al. Safety and efficacy of mechanical thrombectomy in acute ischemic stroke of anticoagulated patients. J NeuroInterv Surg. 2018;Epub ahead of print.
Disclosures:
L'Allinec reports no relevant conflicts of interest.
