Impact of atrial fibrillation on outcomes in stroke patients with tandem occlusions treated with thrombectomy: A multicentre study

Q: What are the key findings of this study?

Atrial fibrillation was associated with significantly lower 90-day functional independence (25.6% vs 40.6%; aRR 0.49, 95% CI 0.31-0.76, p=0.001) after mechanical thrombectomy for tandem occlusions.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Acute ischemic stroke due to anterior circulation tandem occlusions treated with mechanical thrombectomy (n=635). Intervention: Atrial fibrillation (known or newly detected during admission) vs. Patients with tandem occlusion without atrial fibrillation. Primary outcome: Functional independence at 90 days (modified Rankin Scale [mRS] score 0-2) (aRR 0.49, 95% CI 0.31-0.76, p=0.001).

Q: What does this research mean for the field?

Atrial fibrillation is associated with significantly lower rates of 90-day functional independence and higher 90-day mortality in acute ischemic stroke patients with tandem occlusions undergoing mechanical thrombectomy, despite comparable procedural recanalization rates. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Lucio D’Anna; Matteo Foschi; Mariarosaria Valente; Liqun Zhang; Nina Mansoor; Matthew Fallon; Fedra Kuris; Francesco Toraldo; Filippo Komauli; Massimo Sponza; Vladimir Gavrilovic; Kyriakos Lobotesis; Gian Luigi Gigli; Soma Banerjee; Giovanni Merlino

doi:10.1177/17474930251330139

March 14, 2025International Journal of StrokeOpen Access

Impact of atrial fibrillation on outcomes in stroke patients with tandem occlusions treated with thrombectomy: A multicentre study

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Key result

Atrial fibrillation is linked to ~51% lower 90-day functional independence after thrombectomy for tandem occlusions.

aRR 0.49
95% CI 0.31-0.76
P=0.001
n=635

Figures

Graphical abstract published by International Journal of Stroke — Graphical abstract · Published by International Journal of Stroke · CC BY-NC

Why the study?

The impact of atrial fibrillation on outcomes in patients with tandem occlusions treated with mechanical thrombectomy remained unclear.

Does atrial fibrillation affect 90-day functional independence and survival outcomes in acute ischemic stroke patients with anterior circulation tandem occlusions undergoing mechanical thrombectomy?

Key Points

To evaluate the safety and efficacy of mechanical thrombectomy in acute ischemic stroke patients with tandem occlusions, comparing those with atrial fibrillation to those without.
Multicentre, retrospective study of 635 patients with tandem occlusions treated with mechanical thrombectomy across three comprehensive stroke centers.
Applied inverse probability weighting to balance baseline characteristics and adjust for prior oral anticoagulant therapy.
Primary outcome was functional independence at 90 days (modified Rankin Scale score 0–2); secondary outcomes included successful recanalization (TICI ≥ 2b), intracranial hemorrhage, and 90-day mortality.
Favorable 90-day functional outcome occurred in 25.61% of patients with atrial fibrillation versus 40.55% without (adjusted risk ratio [aRR] = 0.49; 95% CI: 0.31–0.76; p = 0.001).
Patients with atrial fibrillation experienced significantly higher 90-day all-cause mortality (aRR = 2.29; 95% CI: 1.47–3.55; p < 0.001).
Rates of successful recanalization, intracerebral hemorrhage, and symptomatic intracerebral hemorrhage were similar between the two groups.

Study Design

Type

Cohort (n=635)

Multicenter

Yes

Structured PICO

Does atrial fibrillation affect 90-day functional independence and survival outcomes in acute ischemic stroke patients with anterior circulation tandem occlusions undergoing mechanical thrombectomy?

P

Population

635 adults (median age 70, 53.2% female) with acute ischemic stroke from anterior circulation tandem occlusions (ASPECTS ≥5, pre-stroke mRS 0-2) treated with mechanical thrombectomy at 3 UK and Italian centers and followed for 90 days.

E

Exposure

Mechanical thrombectomy (MT) of the intracranial occlusion with or without emergent cervical ICA intervention (balloon angioplasty and/or stenting) in patients with atrial fibrillation (Tandem AF, n=164, including 131 with previously known AF and 33 with newly detected AF during hospital admission); intravenous thrombolysis with tissue plasminogen activator (tPA) administered if presenting within 4.5 hours without contraindications.

C

Comparator

Mechanical thrombectomy (MT) of the intracranial occlusion with or without emergent cervical ICA intervention in patients without atrial fibrillation (Tandem, n=471); intravenous thrombolysis with tissue plasminogen activator (tPA) administered if presenting within 4.5 hours without contraindications.

O

Outcome

Functional independence at 90 days (defined by a modified Rankin Scale [mRS] score of 0 to 2) and the 90-day shift in mRS scores, adjudicated by local investigators.hard clinical

Main Result

Relative Risk: 0.49 (95% CI 0.31–0.76)

Absolute Event Rate: 25.61% vs 40.55%

Absolute Risk Reduction: 16.21%

p-value: p=0.001

Limitations

Retrospective post hoc analysis subject to inherent biases and unmeasured confounding despite inverse probability weighting (IPW).
Heterogeneity in procedural techniques and peri-procedural care across participating centers.
IPW did not account for all comorbidities (such as respiratory conditions, heart failure, or valvular disease) typically more prevalent in AF patients.
Outpatient follow-up and monitoring for AF detection after hospital discharge were not included.
Retrospective post hoc analysis subject to inherent biases, including unmeasured confounding, despite the use of inverse probability weighting (IPW).
Heterogeneity in procedural techniques and peri-procedural care across participating centers may have influenced observed outcomes and limited generalizability.
IPW did not account for all comorbidities, such as respiratory conditions and other factors typically more prevalent in AF patients.
Additional outpatient follow-up and monitoring for AF detection were not included in the study.

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

In acute ischemic stroke patients with anterior circulation tandem occlusions undergoing mechanical thrombectomy, concomitant atrial fibrillation is associated with significantly worse 90-day functional independence and higher mortality despite similar procedural recanalization and bleeding rates.

Abstract

Background: Tandem occlusions, involving simultaneous extracranial and intracranial artery blockages, represent a complex subtype of acute ischemic stroke treated with mechanical thrombectomy (MT). However, to date, the impact of atrial fibrillation (AF) on outcomes in this population remains unclear. This study aimed to evaluate the safety and efficacy of MT in patients with tandem occlusions, comparing those with AF to their counterparts without AF. Methods: We performed a multicentre, retrospective study using inverse probability weighting (IPW) to evaluate the effect of AF on outcomes in tandem occlusion patients treated with MT across three comprehensive stroke centers. The primary outcome was functional independence at 90 days (modified Rankin Scale [mRS] 0–2). Secondary outcomes included recanalization success (Treatment in Cerebral Infarction (TICI) ⩾ 2b), intracranial hemorrhage (ICH), symptomatic ICH (sICH), and 90-day mortality. Subgroup analyses assessed the interaction between AF and clinical or procedural factors. Results: Among 635 patients, 164 (25.8%) had AF (Tandem AF ). Tandem AF patients had significantly lower rates of favorable 90-day functional outcomes (adjusted risk ratio [aRR] = 0.49; 95% confidence interval (CI): 0.31–0.76; p = 0.001) and higher 90-day mortality (aRR 2.29; 95% CI: 1.47–3.55; p < 0.001) compared to non-AF patients. Rates of successful recanalization, ICH, and sICH were similar between groups. Subgroup analysis revealed worse outcomes for Tandem AF patients aged ⩾65 years, with National Institute of Health Stroke Scale (NIHSS) 11–42, and those treated with general anesthesia or intravenous thrombolysis. Conclusions: Patients with tandem occlusion and AF undergoing MT showed significantly worse functional and survival outcomes relative to their non-AF counterparts, despite comparable procedural success rates. These findings highlight the critical need for tailored management strategies to mitigate the unique risks associated with AF in this population. Further research is essential to refine therapeutic approaches and improve outcomes for this high-risk group.

Discussion

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Cite This Study

D’Anna et al. (2025) conducted a cohort in Acute ischemic stroke due to anterior circulation tandem occlusions treated with mechanical thrombectomy (n=635). Atrial fibrillation (known or newly detected during admission) vs. Patients with tandem occlusion without atrial fibrillation was evaluated on Functional independence at 90 days (modified Rankin Scale [mRS] score 0-2) (aRR 0.49, 95% CI 0.31-0.76, p=0.001). Atrial fibrillation was associated with significantly lower 90-day functional independence (25.6% vs 40.6%; aRR 0.49, 95% CI 0.31-0.76, p=0.001) after mechanical thrombectomy for tandem occlusions.

synapsesocial.com/papers/6a7f302163e03285017c9eb5 https://doi.org/10.1177/17474930251330139

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Impact of atrial fibrillation on outcomes in stroke patients with tandem occlusions treated with thrombectomy: A multicentre study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Impact of atrial fibrillation on outcomes in stroke patients with tandem occlusions treated with thrombectomy: A multicentre study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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