Background and Purpose: Current guidelines recommend against IV tPA use in patients on warfarin with INR > 1.7, recent use of novel oral anticoagulants (NOACs), or current therapeutic parenteral anticoagulation. These patients are sometimes considered for endovascular thrombolysis, however there is limited data on the safety of this approach. We sought to assess the safety of endovascular intervention in these patients.
Methods: We performed a multicenter retrospective study to identify consecutive patients undergoing endovascular intervention for acute ischemic stroke while on therapeutic anticoagulation (defined as warfarin use with INR > 1.7, heparin with elevated PTT, or recent LMWH or NOAC use). The primary outcome measure was symptomatic ICH (sICH) using the NINDS definition. We compared the observed rate of sICH to risk-adjusted published historical control rates of sICH after IV tPA using weighted averages of the Hemorrhage after Thrombolysis (HAT) and Multicenter Stroke Survey (MSS) prediction scores.
Results: Of 82 cases, mean age was 73 ± 15 years, 46% were female, and median NIHSS was 19 (IQR 14-22). Anticoagulation consisted of warfarin (n=43, mean INR 2.3), IV heparin (n=19), NOACs (n=17), and LMWH (n=3). Any ICH on follow-up CT was present in 26 (32%) patients, and sICH in 7 (8.5%, 95% CI 4.2-16.6) patients. All 7 sICH occurred in patients on warfarin. Severe systemic bleeding occurred in 1 patient. At discharge, 10% subjects returned home, 44% went to an acute rehabilitation facility, 27% to a nursing facility, and 19% had died. Predicted sICH rate for the cohort based on HAT and MSS scoring was 12% and 7% respectively.
Conclusions: Endovascular intervention in subjects on therapeutic anticoagulation appears reasonably safe, with a sICH rate similar to patients not on anticoagulation receiving IV tPA.