Background/Aim: Endovascular thrombectomy may be performed in anticoagulated patients taking vitamin-K antagonists (VKA) or direct-acting oral anticoagulants (DOAC) in whom the use of intravenous tissue plasminogen activator (tPA) is contraindicated. We aimed to investigate the efficacy and safety of mechanical thrombectomy specifically in anticoagulated patients ineligible for thrombolysis. Methods: We performed a retrospective analysis of a prospectively collected database of consecutive ischaemic stroke patients undergoing mechanical thrombectomy from January 2008 to June 2017. Patients receiving any dose of intravenous or intra-arterial thrombolysis were excluded. Patients taking oral anticoagulants (VKAs or DOACs) were compared with non-anticoagulated patients. Outcomes compared between groups included the rate of intracerebral haemorrhage (ICH) on follow-up imaging (ICHany), symptomatic ICH, functional independence at 90 days (modified Rankin scale score, 0–2), mortality, and post-treatment recanalization (Thrombolysis in Cerebral Infarction score ≥2b). Results: In all, 102 patients undergoing mechanical thrombectomy without prior thrombolysis were included in the study. Sixty-six (64.7%) patients were not anticoagulated, 23 (22.5%) patients were taking VKAs, and 13 (12.7%) patients were taking DOACs. There were no significant differences in the rate of ICHany (11.1 vs. 13.6%, p = 0.93) or sICH (2.8 vs. 1.5%, p = 0.14) in anticoagulated patients compared to non-anticoagulated patients. No cases of sICH were observed among patients taking DOACs. After 90 days of follow-up, the rates of functional independence (50.0 vs. 43.1%) and mortality (27.8 vs. 25.8%) were also similar between the anticoagulation and the non-anticoagulation groups. Conclusion: Mechanical thrombectomy appears to be safe and effective in anticoagulated patients ineligible for thrombolysis, with observed haemorrhage rates similar to those of patients not on anticoagulant therapy. However, further multicentre prospective studies are needed, due to the rising number of patients on warfarin and DOACs worldwide.

Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E, et al: Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014; 384: 1929–1935.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al: 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American heart association/American stroke association. Stroke 2018; 49:e46–e110.
Alberts MJ, Eikelboom JW, Hankey GJ: Antithrombotic therapy for stroke prevention in non-valvular atrial fibrillation. Lancet Neurol 2012; 11: 1066–1081.
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372: 11–20.
Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al: Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372: 1019–1030.
Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al: Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372: 2296–2306.
Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al: Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372: 2285–2295.
Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al: Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372: 1009–1018.
Muir KW, Ford GA, Messow CM, Ford I, Murray A, Clifton A, et al: Endovascular therapy for acute ischaemic stroke: the pragmatic ischaemic stroke thrombectomy evaluation (PISTE) randomised, controlled trial. J Neurol Neurosurg Psychiatry 2017; 88: 38–44.
Bracard S, Ducrocq X, Mas JL, Soudant M, Oppenheim C, Moulin T, et al: Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 2016; 15: 1138–1147.
Kurowski D, Jonczak K, Shah Q, Yaghi S, Marshall RS, Ahmad H, et al: Safety of endovascular intervention for stroke on therapeutic anticoagulation: multicenter cohort study and meta-analysis. J Stroke Cerebrovasc Dis 2017; 26: 1104–1109.
Zapata-Wainberg G, Ximenez-Carrillo A, Trillo S, Fuentes B, Cruz-Culebras A, Aguirre C, et al: Mechanical thrombectomy in orally anticoagulated patients with acute ischemic stroke. J Neurointerv Surg 2018; 10: 834–838.
Cernik D, Sanak D, Divisova P, Kocher M, Cihlar F, Zapletalova J, et al: Mechanical thrombectomy in patients with acute ischemic stroke on anticoagulation therapy. Cardiovasc Intervent Radiol 2018; 41: 706–711.
De Marchis GM, Jung S, Colucci G, Meier N, Fischer U, Weck A, et al: Intracranial hemorrhage, outcome, and mortality after intra-arterial therapy for acute ischemic stroke in patients under oral anticoagulants. Stroke 2011; 42: 3061–3066.
Purrucker JC, Wolf M, Haas K, Rizos T, Khan S, Dziewas R, et al: Safety of endovascular thrombectomy in patients receiving non-vitamin K antagonist oral anticoagulants. Stroke 2016; 47: 1127–1130.
Rebello LC, Haussen DC, Belagaje S, Anderson A, Frankel M, Nogueira RG: Endovascular treatment for acute ischemic stroke in the setting of anticoagulation. Stroke 2015; 46: 3536–3539.
Rozeman AD, Wermer MJ, Lycklama a Nijeholt GJ, Dippel DW, Schonewille WJ, Boiten J, et al: Safety of intra-arterial treatment in acute ischaemic stroke patients on oral anticoagulants. A cohort study and systematic review. Eur J Neurol 2016; 23: 290–296.
Seiffge DJ, Hooff RJ, Nolte CH, Bejot Y, Turc G, Ikenberg B, et al: Recanalization therapies in acute ischemic stroke patients: impact of prior treatment with novel oral anticoagulants on bleeding complications and outcome. Circulation 2015; 132: 1261–1269.
Berger C, Fiorelli M, Steiner T, Schabitz WR, Bozzao L, Bluhmki E, et al: Hemorrhagic transformation of ischemic brain tissue: asymptomatic or symptomatic? Stroke 2001; 32: 1330–1335.
Gumbinger C, Gruschka P, Bottinger M, Heerlein K, Barrows R, Hacke W, et al: Improved prediction of poor outcome after thrombolysis using conservative definitions of symptomatic hemorrhage. Stroke 2012; 43: 240–242.
Cheang MY, Manning N, Churilov L, Mitchell P, Dowling R, Yan B: Recanalisation success is associated with good clinical outcome despite advanced age and stroke severity in patients treated with the Solitaire stentriever. J Clin Neurosci 2014; 21: 401–405.
Nogueira RG, Smith WS, Merci, Multi MW: Safety and efficacy of endovascular thrombectomy in patients with abnormal hemostasis: pooled analysis of the MERCI and multi MERCI trials. Stroke 2009; 40: 516–522.
Dorn F, Prothmann S, Patzig M, Lockau H, Kabbasch C, Nikoubashman O, et al: Stent retriever thrombectomy in patients who are ineligible for intravenous thrombolysis: a multicenter retrospective observational study. AJNR Am J Neuroradiol 2016; 37: 305–310.
Benavente L, Larrosa D, Garcia-Cabo C, Perez AI, Rico M, Vega P, et al: Safety and efficacy of mechanical thrombectomy in acute ischemic stroke of anticoagulated patients-A prospective observational study. J Stroke Cerebrovasc Dis 2016; 25: 2093–2098.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.