Mechanical thrombectomy in acute ischaemic stroke patients with pre-interventional intracranial haemorrhage following intravenous thrombolysis

Hanna Styczen,Nuran Abdullayev,Michael Forsting,Hans Henkes,Alex Brehm,Carmen Serna-Candel,Johannes Gerber,Matthias Gawlitza,Marios-Nikos Psychogios,Sebastian Fischer,Volker Maus,Christoph Kabbasch

doi:10.1177/19714009211009112

Abstract

BackgroundData on outcome of endovascular treatment in patients with acute ischaemic stroke due to large vessel occlusion suffering from intravenous thrombolysis-associated intracranial haemorrhage prior to mechanical thrombectomy remain scarce. Addressing this subject, we report our multicentre experience.MethodsA retrospective analysis of consecutive acute ischaemic stroke patients treated with mechanical thrombectomy due to large vessel occlusion despite the pre-interventional occurrence of intravenous thrombolysis-associated intracranial haemorrhage was performed at five tertiary care centres between January 2010–September 2020. Baseline demographics, aetiology of stroke and intracranial haemorrhage, angiographic outcome assessed by the Thrombolysis in Cerebral Infarction score and clinical outcome evaluated by the modified Rankin Scale at 90 days were recorded.ResultsIn total, six patients were included in the study. Five individuals demonstrated cerebral intraparenchymal haemorrhage on pre-interventional imaging; in one patient additional subdural haematoma was observed and one patient suffered from isolated subarachnoid haemorrhage. All patients except one were treated by the ‘drip-and-ship’ paradigm. Successful reperfusion was achieved in 4/6 (67%) individuals. In 5/6 (83%) patients, the pre-interventional intracranial haemorrhage had aggravated in post-interventional computed tomography with space-occupying effect. Overall, five patients had died during the hospital stay. The clinical outcome of the survivor was modified Rankin Scale=4 at 90 days follow-up.ConclusionMechanical thrombectomy in patients with intravenous thrombolysis-associated intracranial haemorrhage is technically feasible. The clinical outcome of this subgroup of stroke patients, however, appears to be devastating with high mortality and only carefully selected patients might benefit from endovascular treatment.

Highlights

Data on outcome of endovascular treatment in patients with acute ischaemic stroke due to large vessel occlusion suffering from intravenous thrombolysis-associated intracranial haemorrhage prior to mechanical thrombectomy remain scarce
Mechanical thrombectomy (MT) in combination with intravenous thrombolysis (IVT) is the standard treatment for patients suffering from acute ischaemic stroke (AIS) due to intracranial large vessel occlusion (LVO) in the anterior circulation.[1,2]
The ongoing SKIP trial in Japan could not establish that skipping IVT was noninferior to the combined approach but was at least associated with a lower risk of intracranial haemorrhage (ICH).[4]

Summary

Introduction

Data on outcome of endovascular treatment in patients with acute ischaemic stroke due to large vessel occlusion suffering from intravenous thrombolysis-associated intracranial haemorrhage prior to mechanical thrombectomy remain scarce. Addressing this subject, we report our multicentre experience. With increasing numbers of patients treated under the ‘drip and ship’ paradigm, the occurrence of an IVTassociated ICH prior to the endovascular procedure is becoming more likely.[7] Studies analysing the benefit of MT in this subgroup are limited as preinterventional ICH remains an exclusion criterion for endovascular therapy in clinical trials.[8] we aimed to report our multicentre experience with MT in patients with AIS due to LVO suffering from IVTassociated ICH

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Conclusion