title: Endovascular stroke therapy may be safe in patients with elevated international normalized ratio.
abstract: BACKGROUND
  Endovascular therapy in acute ischemic stroke is safe and efficient. However, patients receiving oral anticoagulation were excluded in the larger trials.
  
  
  OBJECTIVE
  To analyze the safety of endovascular therapy in patients with acute ischemic stroke and elevated international normalized ratio (INR) values.
  
  
  METHODS
  Retrospective database review of a tertiary care university hospital for patients with anterior circulation stroke treated with endovascular therapy. Patients with anticoagulation other than vitamin K antagonists were excluded. The primary safety endpoint was defined as symptomatic intracranial hemorrhage (sICH; ECASS II definition). The efficacy endpoint was the modified Rankin scale (mRS) score after 3 months, dichotomized into favorable outcome (mRS 0-2) and unfavorable outcome (mRS 3-6).
  
  
  RESULTS
  435 patients were included. 90% were treated with stent retriever. 27 (6.2%) patients with an INR of 1.2-1.7 and 21 (4.8%) with an INR >1.7. 33 (7.6%) had sICH and 149 patients (34.3%) had a favorable outcome. Patients with an elevated INR did not have an increased risk for sICH or unfavorable outcome in multivariable analysis. The additional use of IV thrombolysis in patients with an INR of 1.2-1.7 did not increase the risk of sICH or unfavorable outcome. These results were replicated in a sensitivity analysis introducing an error of the INR of ±5%. They were also confirmed using other sICH definitions (Safe Implementation of Thrombolysis in Stroke (SITS), National Institute of neurological Disorders and Stroke (NINDS), Heidelberg bleeding classification).
  
  
  CONCLUSIONS
  Endovascular therapy in patients with an elevated INR is safe and efficient. Patients with an INR of 1.2-1.7 may be treated with combined IV thrombolysis and endovascular therapy.
authors.affiliation: Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Sibu
authors.identifier: http://orcid.org/0000-0003-4637-4641
authors.initials: S
authors.lastname: Mundiyanapurath
authors.affiliation: Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Anne
authors.initials: A
authors.lastname: Tillmann
authors.affiliation: Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Markus Alfred
authors.initials: MA
authors.lastname: Möhlenbruch
authors.affiliation: Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Bendszus
authors.affiliation: Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Peter Arthur
authors.initials: PA
authors.lastname: Ringleb
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000097:blood* / Q000175:diagnosis / Q000601:surgery*; D016208:Databases, Factual / Q000639:trends; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D019934:International Normalized Ratio / Q000639:trends*; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D020521:Stroke / Q000097:blood* / Q000175:diagnosis / Q000601:surgery*; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents
keywords: Stroke; Thrombectomy