Safety of Recanalization Therapy in Patients with Acute Ischemic Stroke Under Anticoagulation: A Systematic Review and Meta-Analysis

Liu, Mingsu; Yang, Zuozhang; Li, Guangqin

doi:10.1016/j.jstrokecerebrovasdis.2018.04.012

Cited by 23 publications

(21 citation statements)

References 61 publications

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“…Use of VKA was associated with worse functional outcome at 3 months in bivariate analysis but did not predict functional dependence in the multivariate regression model, in accordance with a recent study (6). This lack of association with poor functional outcome could be due to the role of confounding factors associated with the use of VKA, such as age, comorbidities, premorbid status, or higher incidence of atrial fibrillation (17) in patients under VKA treatment compared with nonanticoagulated patients.…”

Section: Discussionsupporting

confidence: 87%

“…According to our results, we can affirm that EVT is safe and feasible in the context of previous anticoagulation as previously reported (22). Our proportion of anticoagulated patients subjected to EVT (19%) is slightly higher than rates reported in most recently published data (6); this emphasizes the importance of the occurrence of stroke in previous anticoagulated patients who will further require reperfusion therapy (17). Our rate of sICH is 5.6%, which is also in line with the proportion reported in recent series of patients with AIS treated with mechanical thrombectomy (1,6).…”

Section: Discussionsupporting

confidence: 86%

“…The distribution of baseline variables of the study group is shown in Table 1. Six hundred and sixty-four patients (46%) were women, the mean age of the overall population was 72.42 years (SD: 12.84) and median NIHSS at admission was 16 (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20). Two hundred and seventy-four patients (19%) were on oral anticoagulants, 193 on VKA (70%) and 81 (30%) on DOACs.…”

Section: Resultsmentioning

confidence: 99%

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Oral Anticoagulation and Risk of Symptomatic Hemorrhagic Transformation in Stroke Patients Treated With Mechanical Thrombectomy: Data From the Nordictus Registry

et al. 2020

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Introduction: We aimed to evaluate if prior oral anticoagulation (OAC) and its type determines a greater risk of symptomatic hemorrhagic transformation in patients with acute ischemic stroke (AIS) subjected to mechanical thrombectomy.Materials and Methods: Consecutive patients with AIS included in the prospective reperfusion registry NORDICTUS, a network of tertiary stroke centers in Northern Spain, from January 2017 to December 2019 were included. Prior use of oral anticoagulants, baseline variables, and international normalized ratio (INR) on admission were recorded. Symptomatic intracranial hemorrhage (sICH) was the primary outcome measure. Secondary outcome was the relation between INR and sICH, and we evaluated mortality and functional outcome at 3 months by modified Rankin scale. We compared patients with and without previous OAC and also considered the type of oral anticoagulants.Results: About 1.455 AIS patients were included, of whom 274 (19%) were on OAC, 193 (70%) on vitamin K antagonists (VKA), and 81 (30%) on direct oral anticoagulants (DOACs). Anticoagulated patients were older and had more comorbidities. Eighty-one (5.6%) developed sICH, which was more frequent in the VKA group, but not in DOAC group. OAC with VKA emerged as a predictor of sICH in a multivariate regression model (OR, 1.89 [95% CI, 1.01–3.51], p = 0.04) and was not related to INR level on admission. Prior VKA use was not associated with worse outcome in the multivariate regression model nor with mortality at 3 months.Conclusions: OAC with VKA, but not with DOACs, was an independent predictor of sICH after mechanical thrombectomy. This excess risk was associated neither with INR value by the time thrombectomy was performed, nor with a worse functional outcome or mortality at 3 months.

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Section: Discussionsupporting

confidence: 87%

Section: Discussionsupporting

confidence: 86%

Section: Resultsmentioning

confidence: 99%

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Oral Anticoagulation and Risk of Symptomatic Hemorrhagic Transformation in Stroke Patients Treated With Mechanical Thrombectomy: Data From the Nordictus Registry

et al. 2020

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“…EVT also seems to be safe and effective in large vessel occlusion (LVO) in patients undergoing NOAC therapy, but further trials are needed to confirm general safety [60,87]. Either on its own or in combination with, recanalization strategies are available for about one out of three patients with an AIS undergoing therapy with a NOAC [47].…”

Section: Discussionmentioning

confidence: 99%

Clinical presentation, diagnostic findings and management of cerebral ischemic events in patients on treatment with non-vitamin K antagonist oral anticoagulants – A systematic review

et al. 2019

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Background Non-vitamin K antagonist oral anticoagulants (NOAC) are equally or potentially superior in terms of effectiveness in the prevention of ischemic stroke and carry a lower associated risk of intracranial hemorrhage compared to Vitamin K antagonists. Nevertheless, ischemic strokes also occur in patients who are being treated with NOAC. In those particular patients, knowledge about the underlying stroke etiology, clinical presentation, acute management, and complication rates is scarce. Objective Systematic literature review to provide a comprehensive clinical overview in terms of presentation, laboratory, imaging parameters and outcomes of patients suffering from acute cerebral ischemic events (i.e. TIA and acute ischemic stroke) while on treatment with a NOAC. Only if available, comparison to VKA is presented which was not the primary focus of this analysis. Data sources PubMed/MEDLINE, Scopus and EMBASE from January 1, 2006, to November 20, 2018. Study eligibility criteria 52 studies providing detailed information on a total of 12247 patients were included. We excluded case reports and case series with less than five patients. Study appraisal and synthesis method We systematically assessed study quality using a bias tool and pooled consistent data. Results Existing data indicates milder stroke severity and smaller infarct size of acute ischemic stroke on treatment with NOAC compared to stroke occurrence on Vitamin K antagonists (VKA). Established risk factors for ischemic events also play a role in stroke while on NOACs, albeit the underlying etiology remains poorly understood. Intravenous thrombolysis and endovascular therapy seem to be safe and effective, but patient selection for recanalization therapies is challenging. Limitations Limited quality of published data, duplicate cases, statistical issues of data pooling, possible incomplete retrieval of identified research and reporting bias might have limited our findings. Conclusions Acute ischemic events despite treatment with NOAC therapy are insufficiently investigated. Systematic review registration number PROSPERO: CRD42018074853.

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“…28 Other work has suggested similar findings. 29 One caveat, however, is that there may be characteristics inherent to the patient, requiring the Open access patient to be taking a VKA, which also put them at higher risk for sICH, rather than this effect being simply due to the medication use. Current guidelines are clear about avoiding treatment with intravenous rtPA in patients who had a stroke on AC for cardiac indications, but based on the evidence, ET-based reperfusion therapy should not be delayed.…”

Section: Ac Use For Cardiac Indicationsmentioning

confidence: 99%

Bleeding risk in patients with cardiac disease from ischaemic stroke reperfusion therapy: an update

Chen

Johansen

2021

BMJ Neurol Open

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BackgroundIntravenous tissue plasminogen activator (rtPA) and arterial endovascular therapy (ET) rapidly restore cerebral perfusion in eligible patients who had an acute ischaemic stroke (AIS). It is unknown whether patients who had an AIS with premorbid cardiac disease respond differently to reperfusion therapies than those without. These patients may have risk factors that worsen outcomes or may represent those who would most benefit from reperfusion therapy.ObjectiveTo determine whether patients who had an AIS with the most frequently encountered pre-existing cardiac conditions, atrial fibrillation (AF), heart failure (HF), left ventricular assist devices (LVADs), or taking anticoagulation for cardiac indications, are at increased risk for poor outcome, such as symptomatic intracranial haemorrhage (sICH), after reperfusion therapy.ResultsAlthough AF is an independent risk factor for poor poststroke outcomes, intravenous rtPA is not associated with increased risk of sICH for those not on anticoagulants. Likewise, HF is independently associated with mortality post stroke, yet these patients benefit from reperfusion therapies without increased rates of sICH. Patients with LVADs or who are on anticoagulation should not be given IV rtPA; however, ET remains a viable option in those who meet criteria, even patients with LVAD.ConclusionThere is no evidence of an increased risk for sICH after intravenous rtPA or ET for those with AF or HF. Intravenous rtPA should not be given to patients on anticoagulation or with LVADs, but ET should be offered to them when eligible. Whenever possible, future AIS reperfusion research should include patients with premorbid cardiac disease as they are frequently excluded, representing a gap in evidence.

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Safety of Recanalization Therapy in Patients with Acute Ischemic Stroke Under Anticoagulation: A Systematic Review and Meta-Analysis

Cited by 23 publications

References 61 publications

Oral Anticoagulation and Risk of Symptomatic Hemorrhagic Transformation in Stroke Patients Treated With Mechanical Thrombectomy: Data From the Nordictus Registry

Oral Anticoagulation and Risk of Symptomatic Hemorrhagic Transformation in Stroke Patients Treated With Mechanical Thrombectomy: Data From the Nordictus Registry

Clinical presentation, diagnostic findings and management of cerebral ischemic events in patients on treatment with non-vitamin K antagonist oral anticoagulants – A systematic review

Bleeding risk in patients with cardiac disease from ischaemic stroke reperfusion therapy: an update

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