Pasquale Mordasini1, Urs Fischer2, Johannes Kaesmacher1,3, Thomas R Meinel2, Stefania Nannoni4, Marta Olivé-Gadea5, Eike I Piechowiak1, Christian Maegerlein6, Martina Goeldlin2, Laurent Pierot7, David J Seiffge2, Vitor Mendes Pereira8, Mirjam R Heldner2, Lorenz Grunder3, Vincent Costalat9, Marcel Arnold2, Tomas Dobrocky1, Jan Gralla1. 1. University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.P., T.D., J.G., P.M.), University Hospital Bern, Inselspital, University of Bern, Switzerland. 2. Department of Neurology (T.R.M., M.G., D.S., M.R.H., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland. 3. University Institute of Diagnostic and Interventional and Pediatric Radiology (J.K., L.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland. 4. Stroke Centre and Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland (S.N.). 5. Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M.O.-G.). 6. Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M.). 7. Department of Neuroradiology, CHU Reims, France (L.P.). 8. Joint Department of Medical Imaging, Toronto Western Hospital, ON, Canada (V.M.P.). 9. Department of Neuroradiology, CHU Montpellier, France (V.C.).
Abstract
BACKGROUND AND PURPOSE: Whether intravenous thrombolysis (IVT) increases the risk for symptomatic intracranial hemorrhage (sICH) in patients treated with mechanical thrombectomy (MT) is a matter of debate. Purpose of this study was to evaluate the extent of early ischemia as a possible factor influencing the risk for sICH after IVT+MT versus direct MT. METHODS: An explorative analysis of the BEYOND-SWIFT (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy) multicenter cohort was performed. We hypothesized that the sICH risk between IVT+MT versus direct MT differs across the strata of Alberta Stroke Program Early CT Scores (ASPECTS). For this purpose, all patients with ICA, M1, and M2 vessel occlusions and available noncontrast computed tomography or diffusion-weighed imaging ASPECTS (n=2002) were analyzed. We used logistic regression analysis in subgroups, as well as interaction terms, to address the risk of sICH in IVT+MT versus direct MT patients across the ASPECTS strata. RESULTS: In 2002 patients (median age, 73.7 years; 50.7% women; median National Institutes of Health Stroke Scale score, 16), the overall rate of sICH was 6.5% (95% CI, 5.5%-7.7%). Risk of sICH differed across ASPECTS groups (9-10: 6.3%; 6-8: 5.6% and ≤5 9.8%; P=0.042). With decreasing ASPECTS, the risks of sICH in the IVT+MT versus the direct MT group increased from adjusted odds ratio of 0.61 ([95% CI, 0.24-1.60] ASPECTS 9-10), to 1.72 ([95% CI, 0.69-4.24] ASPECTS 6-8) and 6.31 ([95% CI, 1.87-21.29] ASPECTS ≤5), yielding a positive interaction term (1.91 [95% CI, 1.01-3.63]). Sensitivity analyses regarding diffusion-weighed imaging versus noncontrast computed tomography ASPECTS did not alter the primary observations. CONCLUSIONS: The extent of early ischemia may influence relative risks of sICH in IVT+MT versus direct MT patients, with an excess sICH risk in IVT+MT patients with low ASPECTS. If confirmed in post hoc analyses of randomized controlled trial data, IVT may be administered more carefully in patients with low ASPECTS eligible for and with direct access to MT.
BACKGROUND AND PURPOSE: Whether intravenous thrombolysis (IVT) increases the risk for symptomatic intracranial hemorrhage (sICH) in patients treated with mechanical thrombectomy (MT) is a matter of debate. Purpose of this study was to evaluate the extent of early ischemia as a possible factor influencing the risk for sICH after IVT+MT versus direct MT. METHODS: An explorative analysis of the BEYOND-SWIFT (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy) multicenter cohort was performed. We hypothesized that the sICH risk between IVT+MT versus direct MT differs across the strata of Alberta Stroke Program Early CT Scores (ASPECTS). For this purpose, all patients with ICA, M1, and M2 vessel occlusions and available noncontrast computed tomography or diffusion-weighed imaging ASPECTS (n=2002) were analyzed. We used logistic regression analysis in subgroups, as well as interaction terms, to address the risk of sICH in IVT+MT versus direct MT patients across the ASPECTS strata. RESULTS: In 2002 patients (median age, 73.7 years; 50.7% women; median National Institutes of Health Stroke Scale score, 16), the overall rate of sICH was 6.5% (95% CI, 5.5%-7.7%). Risk of sICH differed across ASPECTS groups (9-10: 6.3%; 6-8: 5.6% and ≤5 9.8%; P=0.042). With decreasing ASPECTS, the risks of sICH in the IVT+MT versus the direct MT group increased from adjusted odds ratio of 0.61 ([95% CI, 0.24-1.60] ASPECTS 9-10), to 1.72 ([95% CI, 0.69-4.24] ASPECTS 6-8) and 6.31 ([95% CI, 1.87-21.29] ASPECTS ≤5), yielding a positive interaction term (1.91 [95% CI, 1.01-3.63]). Sensitivity analyses regarding diffusion-weighed imaging versus noncontrast computed tomography ASPECTS did not alter the primary observations. CONCLUSIONS: The extent of early ischemia may influence relative risks of sICH in IVT+MT versus direct MT patients, with an excess sICH risk in IVT+MT patients with low ASPECTS. If confirmed in post hoc analyses of randomized controlled trial data, IVT may be administered more carefully in patients with low ASPECTS eligible for and with direct access to MT.
Authors: Adnan Mujanovic; Christoph C Kurmann; Tomas Dobrocky; Marta Olivé-Gadea; Christian Maegerlein; Laurent Pierot; Vitor Mendes Pereira; Vincent Costalat; Marios Psychogios; Patrik Michel; Morin Beyeler; Eike I Piechowiak; David J Seiffge; Pasquale Mordasini; Marcel Arnold; Jan Gralla; Urs Fischer; Johannes Kaesmacher; Thomas R Meinel Journal: Front Neurol Date: 2022-08-03 Impact factor: 4.086
Authors: Jan Christoph Purrucker; Miriam Heyse; Simon Nagel; Christoph Gumbinger; Fatih Seker; Markus Möhlenbruch; Peter Arthur Ringleb Journal: Stroke Vasc Neurol Date: 2021-07-26