Effect of INR on Outcomes of Endovascular Treatment for Acute Vertebrobasilar Artery Occlusion
Translational Stroke Research - Trang 1-9 - 2023
Tóm tắt
Endovascular treatment (EVT) has been proven to be the standard treatment for acute vertebrobasilar artery occlusion (VBAO). This study aimed to analyze the effects of international normalized ratio (INR) indicators on outcomes in patients with acute VBAO treated with EVT. Dynamic data on INR in patients with VBAO who received endovascular treatment (EVT) at 65 stroke centers in China were retrospectively enrolled. Outcome measures included the modified Rankin Scale (mRS) score at 90 days and 1 year and symptomatic intracranial hemorrhage (sICH). The associations between elevated INR (INR > 1.1), INR variability (time-weighted variance of INR changes), and various clinical outcomes were analyzed in all patients and subgroups stratified by oral anticoagulation (OAC) by mixed logistic regression analysis. A total of 1825 patients met the study criteria, of which 1384 had normal INR and 441 had elevated INR. Multivariate analysis showed that elevated INR was significantly associated with poor functional outcomes (mRS 4–6) at 90 days (odds ratio [OR] 1.36, 95% confidence interval [CI] 1.08–1.72) and 1 year (OR 1.32, 95% CI 1.05–1.66), but was not associated with an increased risk of sICH (OR 1.00, 95% CI 0.83–1.20). Similar associations exist between INR variability and poor functional outcomes at 90 days (OR 2.17, 95% CI 1.09–4.30), 1 year (OR 2.28, 95% CI 1.16–4.46), and sICH (OR 1.11, 95% CI 0.93–1.33). Subgroup analyses further revealed that elevated INR and INR variability remained associated with poor functional outcomes in patients not receiving oral anticoagulation (OAC) therapy, while no significant associations were observed in OAC-treated patients, regardless of whether they were on warfarin or direct oral anticoagulants. Elevated INR and INR variability in VBAO patients treated with EVT were associated with poor functional outcomes. The mechanism underlying the association between elevated INR and poor functional outcomes might be attributed to the fact that elevated INR indirectly reflects the burden of comorbidities, which could independently worsen outcomes. These findings underscore the importance of a comprehensive and dynamic evaluation of INR levels in the management of VBAO patients receiving EVT, providing valuable insights for optimizing patient outcomes.
Tài liệu tham khảo
Boeckh-Behrens T, Pree D, Lummel N, et al. Vertebral artery patency and thrombectomy in basilar artery occlusions. Stroke. 2019;50(2):389–95.
Mattle HP, Arnold M, Lindsberg PJ, et al. Basilar artery occlusion. Lancet Neurol. 2011;10(11):1002–14.
Hacke W, Zeumer H, Ferbert A, et al. Intra-arterial thrombolytic therapy improves outcome in patients with acute vertebrobasilar occlusive disease. Stroke. 1988;19(10):1216–22.
Tao C, Nogueira RG, Zhu Y, et al. Trial of endovascular treatment of acute basilar-artery occlusion. N Engl J Med. 2022;387(15):1361–72.
Jovin TG, Li C, Wu L, et al. Trial of thrombectomy 6 to 24 hours after stroke due to basilar-artery occlusion. N Engl J Med. 2022;387(15):1373–84.
del Zoppo GJ, Levy DE, Wasiewski WW, et al. Hyperfibrinogenemia and functional outcome from acute ischemic stroke. Stroke. 2009;40(5):1687–91.
Turaj W, Słowik A, Dziedzic T, et al. Increased plasma fibrinogen predicts one-year mortality in patients with acute ischemic stroke. J Neurol Sci. 2006;246(1–2):13–9.
Zhang J, Liu L, Tao J, et al. Prognostic role of early D-dimer level in patients with acute ischemic stroke. PLoS One. 2019;14(2):e0211458.
Welsh P, Barber M, Langhorne P, et al. Associations of inflammatory and haemostatic biomarkers with poor outcome in acute ischaemic stroke. Cerebrovasc Dis. 2009;27(3):247–53.
Ignjatovic V. Prothrombin time/international normalized ratio. Methods Mol Biol. 2013;992:121–9.
Verma A, Kole T. International normalized ratio as a predictor of mortality in trauma patients in India. World J Emerg Med. 2014;5(3):192–5.
Okada A, Sugano Y, Nagai T, et al. Prognostic value of prothrombin time international normalized ratio in acute decompensated heart failure – a combined marker of hepatic insufficiency and hemostatic abnormality. Circ J. 2016;80(4):913–23.
Kırış T, Yazıcı S, Durmuş G, et al. The relation between international normalized ratio and mortality in acute pulmonary embolism: A retrospective study. J Clin Lab Anal. 2018;32(1):e22164.
Xie X, Wang X, Li Z, et al. Prognostic value of international normalized ratio in ischemic stroke patients without atrial fibrillation or anticoagulation therapy. J Atheroscler Thromb. 2019;26(4):378–87.
You S, Han Q, Dong X, et al. Prognostic significance of international normalised ratio and prothrombin time in Chinese acute ischaemic stroke patients. Postgrad Med J. 2023;99(1170):333–39.
Chen H, Ahmad G, Colasurdo M, et al. Mildly elevated INR is associated with worse outcomes following mechanical thrombectomy for acute ischemic stroke. J Neurointerv Surg. 2022;jnis-2022-019283.
Scheitz JF, Turc G, Kujala L, et al. Intracerebral hemorrhage and outcome after thrombolysis in stroke patients using selective serotonin-reuptake inhibitors. Stroke. 2017;48(12):3239–44.
Pfeilschifter W, Spitzer D, Czech-Zechmeister B, et al. Increased risk of hemorrhagic transformation in ischemic stroke occurring during warfarin anticoagulation: an experimental study in mice. Stroke. 2011;42(4):1116–21.
Toni D, Fiorelli M, Bastianello S, et al. Hemorrhagic transformation of brain infarct: predictability in the first 5 hours from stroke onset and influence on clinical outcome. Neurology. 1996;46(2):341–5.
Zhang G, He M, Xu Y, et al. Hemoglobin A1c predicts hemorrhagic transformation and poor outcomes after acute anterior stroke. Eur J Neurol. 2018;25(12):1432-e122.
Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723–31.
Langezaal LCM, van der Hoeven EJRJ, Mont’Alverne FJA, et al. Endovascular therapy for stroke due to basilar-artery occlusion. N Engl J Med. 2021;384(20):1910–20.
Liu X, Dai Q, Ye R, et al. Endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion (BEST): an open-label, randomised controlled trial. Lancet Neurol. 2020;19(2):115–22.
Adams HP, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35–41.
Puetz V, Sylaja PN, Coutts SB, et al. Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion. Stroke. 2008;39(9):2485–90.
Singer OC, Berkefeld J, Nolte CH, et al. Mechanical recanalization in basilar artery occlusion: the ENDOSTROKE study. Ann Neurol. 2015;77(3):415–24.
Zaidat OO, Yoo AJ, Khatri P, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke. 2013;44(9):2650–63.
Fihn SD, Gadisseur AAP, Pasterkamp E, et al. Comparison of control and stability of oral anticoagulant therapy using acenocoumarol versus phenprocoumon. Thromb Haemost. 2003;90(2):260–6.
Xiao L, Gu M, Lu Y, et al. Influence of renal impairment on clinical outcomes after endovascular recanalization in vertebrobasilar artery occlusions. J Neurointerv Surg. 2022;14(11):1077–83.
von Kummer R, Broderick JP, Campbell BCV, et al. The Heidelberg bleeding classification: classification of bleeding events after ischemic stroke and reperfusion therapy. Stroke. 2015;46(10):2981–6.
Zi W, Qiu Z, Wu D, et al. Assessment of endovascular treatment for acute basilar artery occlusion via a nationwide prospective registry. JAMA Neurol. 2020;77(5):561–73.
Tamim H, Habbal M, Saliba A, et al. Preoperative INR and postoperative major bleeding and mortality: a retrospective cohort study. J Thromb Thrombolysis. 2016;41(2):301–11.
Mosnier LO, Zlokovic BV, Griffin JH. The cytoprotective protein C pathway. Blood. 2007;109(8):3161–72.
Sadat U, Weerakkody RA, Bowden DJ, et al. Utility of high resolution MR imaging to assess carotid plaque morphology: a comparison of acute symptomatic, recently symptomatic and asymptomatic patients with carotid artery disease. Atherosclerosis. 2009;207(2):434–9.
Delgado GE, Zirlik A, Gruber R, et al. The association of high-normal international-normalized-ratio (INR) with mortality in patients referred for coronary angiography. PLoS One. 2019;14(8): e0221112.