Pathophysiological determinants of worse stroke outcome in atrial fibrillation.
BACKGROUND
The reasons for worse outcome following ischemic stroke in patients with atrial fibrillation (AF) remain unclear. We aimed to elucidate the pathophysiological determinants of poorer stroke outcome in patients with AF using systematic MRI data from the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET).


METHODS
Comparisons of infarct size, hypoperfusion volume, infarct growth, arterial occlusion, recanalization, reperfusion, hemorrhagic transformation and stroke severity were made between patients with and without AF enrolled in the EPITHET study.


RESULTS
AF was present in 42 of 101 patients. At baseline, AF patients were older (79 vs. 73 years, p = 0.02), had more severe neurological impairment (National Institutes of Health Stroke Scale score 16 vs. 11, p = 0.006), larger infarcts (29 vs. 15 ml, p = 0.04) and greater volumes of more severe hypoperfusion (T(max) > or =8 s, perfusion-weighted imaging volume 70 vs. 43 ml, p = 0.01) compared to patients without AF. There were no significant differences in arterial occlusion site, infarct growth, recanalization or reperfusion. At outcome, AF patients had larger infarcts (52 vs. 16 ml, p = 0.05), more severe hemorrhagic transformation (29 vs. 5%, p = 0.002 for parenchymal hematomas), greater disability (modified Rankin Scale score 4 vs. 3, p = 0.03) and higher mortality rates (31 vs. 12%, p = 0.04). AF was an independent predictor of parenchymal hematoma (OR = 6.90, 95% CI = 1.57-30.25), but not mortality (OR = 2.56, 95% CI = 0.83-7.85).


CONCLUSIONS
Patients with AF have worse clinical and imaging outcomes following ischemic stroke. This study suggests that the adverse effect of AF is due to greater volumes of more severely hypoperfused tissue, leading to larger infarct size and greater risk of severe hemorrhagic transformation.
Tu
Hans T H
HT
Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville, Vic. 3050, Australia.
Campbell
Bruce C V
BC
Christensen
Soren
S
Collins
Marnie
M
De Silva
Deidre A
DA
Butcher
Kenneth S
KS
Parsons
Mark W
MW
Desmond
Patricia M
PM
Barber
P Alan
PA
Levi
Christopher R
CR
Bladin
Christopher F
CF
Donnan
Geoffrey A
GA
Davis
Stephen M
SM
D000368:Aged; D000369:Aged, 80 and over; D001157:Arterial Occlusive Diseases / Q000473:pathology / Q000503:physiopathology*; D001281:Atrial Fibrillation / Q000150:complications / Q000503:physiopathology*; D002543:Cerebral Hemorrhage / Q000473:pathology / Q000503:physiopathology*; D002544:Cerebral Infarction / Q000473:pathology / Q000503:physiopathology*; D004311:Double-Blind Method; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000188:drug therapy / Q000209:etiology / Q000503:physiopathology*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator