Abstract
Introduction
: Introduction There is a growing body of literature on concurrent use of MT and IA tPA use in acute large vessel occlusion ischemic stroke, but few address the risk of IA tPA use in patients also receiving IV tPA or baseline anticoagulation1,23. This cohort study aims to assess the rate of improved functional outcome and complications in patients receiving MT plus IA tPA with or without IV‐tPA or baseline anticoagulation.
Methods
: In this single institution, retrospective cohort study, medical records of 114 patients undergoing MT who received concurrent IA‐tPA were identified and reviewed. Parameters such as age, sex, admission/discharge mRS scale and NIHSS score, INR, history of anticoagulation use, concomitant IV‐tPA and complications such as any hemorrhage and in hospital death were reviewed. Patients were divided into two groups and two subgroups. First group included patients treated with IA‐tPA who also received IV‐tPA, had an INR above 1.7 or were on anticoagulation therapy. The second group was composed of patients who only received concurrent IA‐tPA. The primary outcomes were hemorrhage, all cause mortality, and good functional outcome (modified Rankin scale equal to or less than 2). The results were calculated and t‐test for two samples analysis was conducted with one‐tail p‐value (<0.05).
Results
: 74 patients were included in the first group receiving IA‐tPA with either IV‐tPA, or elevated INR or anticoagulated while 40 patients were in the only concurrent IA‐tPA group. 72% versus 60% of the groups respectively have an mRS less or equal to 2 on discharge, p‐value 0.07. 41% of the first group had some type of bleeding on repeat imaging compared to 25% in the IA‐tPA only group, p‐value 0.03. In a subgroup analysis, IV‐tPA alone without prior anticoagulation treatment or an elevated INR, when given in conjunction with IA‐tPA, was an independent risk factor that increased rate of bleeding, 42% versus 25% with a p‐value of 0.04 with an attributable risk of 32%. There was no difference in in‐hospital death rate between the groups.
Conclusions
: This study shows that in patients receiving MT with concurrent IA tPA with elevated INR>1.7, treatment with anticoagulation at baseline, or concomitant IV‐tPA use increases the risk of hemorrhagic conversion. Therefore, there is a need for careful selection of patients receiving concurrent IA‐tPA. Further investigation is warranted to elucidate which patient groups might maximally benefit from IA‐tPA.