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Thrombolysis is an Independent Risk Factor for Poor Outcome After Carotid Revascularization
Ananth K Vellimana1, Chad W Washington1, Chester K Yarbrough1
1Department of Neurological Surgery, Washington University School of Medi-cine, St. Louis, Missouri.
Insights
Thrombolysis for acute ischemic stroke increases risks of hemorrhage and stroke after carotid revascularization. However, these risks decrease significantly within 7 days, suggesting a potential benefit in delaying procedures for stroke patients.
Area of Science:
- Neurology
- Vascular Surgery
- Emergency Medicine
Background:
- Thrombolysis is standard for acute ischemic stroke.
- Early carotid revascularization may reduce recurrent ischemia risk.
- Safety of early revascularization post-thrombolysis is uncertain.
Purpose of the Study:
- Evaluate safety of carotid revascularization in patients treated with thrombolysis for acute ischemic stroke.
Main Methods:
- Analyzed Nationwide Inpatient Sample database for 310,257 patients with carotid stenosis/occlusion.
- Compared outcomes (intracerebral hemorrhage, postprocedural stroke, mortality) between patients receiving thrombolysis (tPA) and those who did not, before carotid endarterectomy (CEA) or angioplasty/stenting (CAS).
Main Results:
- Thrombolysis (tPA) significantly increased risk of intracerebral hemorrhage (ICH) and postprocedural stroke (PPS) after CEA or CAS.
- This elevated risk of ICH/PPS diminished by 7 days post-thrombolysis.
- tPA-treated patients undergoing revascularization had higher rates of poor outcome and in-hospital mortality.
Conclusions:
- Thrombolysis is a significant risk factor for adverse events following carotid revascularization.
- Delaying carotid revascularization after thrombolysis may mitigate risks of ICH and PPS.
- Further research is needed to balance risks of delayed revascularization versus early intervention.
Background:
Thrombolysis is the standard of care for acute ischemic stroke patients presenting in the appropriate time window. Studies suggest that the risk of recurrent ischemia is lower if carotid revascularization is performed early after the index event. The safety of early carotid revascularization in this patient population is unclear.
Objective:
To evaluate the safety of carotid revascularization in patients who received thrombolysis for acute ischemic stroke.
Methods:
The Nationwide Inpatient Sample database was queried for patients admitted through the emergency room with a primary diagnosis of carotid stenosis and/or occlusion. Each patient was reviewed for administration of thrombolysis, carotid endarterectomy, (CEA) or carotid angioplasty and stenting (CAS). Primary endpoints were intracerebral hemorrhage (ICH), postprocedural stroke (PPS), poor outcome, and in-hospital mortality. Potential risk factors were examined using univariate and multivariate analyses.
Results:
A total of 310 257 patients were analyzed. Patients who received tissue plasminogen activator (tPA) and underwent either CEA or CAS had a significantly higher risk of developing an ICH or PPS than patients who underwent either CEA or CAS without tPA administration. The increased risk of ICH or PPS in tPA-treated patients who underwent carotid revascularization diminished with time, and became similar to patients who underwent carotid revascularization without tPA administration by 7 d after thrombolysis. Patients who received tPA and underwent CEA or CAS also had higher odds of poor outcome and in-hospital mortality.
Conclusion:
Thrombolysis is a strong risk factor for ICH, PPS, poor outcome, and in-hospital mortality in patients with carotid stenosis/occlusion who undergo carotid revascularization. The increased risk of ICH or PPS due to tPA declines with time after thrombolysis. Delaying carotid revascularization in these patients may therefore be appropriate. This delay, however, will expose these patients to the risk of recurrent stroke. Future studies are needed to determine the relative risks of these 2 adverse events.
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