Thrombolysis in Postoperative Stroke

Nicolas Voelkel, MD; Nikolai Dominik Hubert, MSc; Roland Backhaus, MD; Roman Ludwig Haberl, MD; Gordian Jan Hubert, MD

Disclosures

Stroke. 2017;48(11):3034-3039. 

In This Article

Abstract and Introduction

Abstract

Background and Purpose: Intravenous thrombolysis (IVT) is beneficial in reducing disability in selected patients with acute ischemic stroke. There are numerous contraindications to IVT. One is recent surgery. The aim of this study was to analyze the safety of IVT in patients with postoperative stroke.

Methods: Data of consecutive IVT patients from the Telemedical Project for Integrative Stroke Care thrombolysis registry (February 2003 to October 2014; n=4848) were retrospectively searched for keywords indicating preceding surgery. Patients were included if surgery was performed within the last 90 days before stroke. The primary outcome was defined as surgical site hemorrhage. Subgroups with major/minor surgery and recent/nonrecent surgery (within 10 days before IVT) were analyzed separately.

Results: One hundred thirty-four patients underwent surgical intervention before IVT. Surgery had been performed recently (days 1–10) in 49 (37%) and nonrecently (days 11–90) in 85 patients (63%). In 86 patients (64%), surgery was classified as major, and in 48 (36%) as minor. Nine patients (7%) developed surgical site hemorrhage after IVT, of whom 4 (3%) were serious, but none was fatal. One fatal bleeding occurred remotely from surgical area. Rate of surgical site hemorrhage was significantly higher in recent than in nonrecent surgery (14.3% versus 2.4%, respectively, odds ratioadjusted 10.73; 95% confidence interval, 1.88–61.27). Difference between patients with major and minor surgeries was less distinct (8.1% and 4.2%, respectively; odds ratioadjusted 4.03; 95% confidence interval, 0.65–25.04). Overall in-hospital mortality was 8.2%. Intracranial hemorrhage occurred in 9.7% and was asymptomatic in all cases.

Conclusions: IVT may be administered safely in postoperative patients as off-label use after appropriate risk–benefit assessment. However, bleeding risk in surgical area should be taken into account particularly in patients who have undergone surgery shortly before stroke onset.

Introduction

Intravenous thrombolysis (IVT) with recombinant tissue-type plasminogen activator (tPA) within the 4.5-hour time window significantly improves the outcome of patients with acute ischemic stroke.[1] There are numerous contraindications for treatment with recombinant tPA, some of which are controversial. Some have been studied extensively and are considered as being relative contraindications, such as previous stroke and diabetes mellitus, any stroke within the last 3 months, age >80 years, and National Institute of Health Stroke Scale score <4 or >25.[2] However, the clinical relevance of some other contraindications remains controversial because of the lack of available data. One of these is the contraindication for thrombolytic treatment in postoperative stroke. It is thought that administering IVT in postoperative patients carries a significant risk of surgical site hemorrhage (SSH). The US Food and Drug Administration package insert quotes "recent major operation", and some European restrictions quote "operation within the past three months" as a contraindication. By now, mainly case reports or small case series have been published on patients with stroke receiving IVT after surgery yet.[3–6]

The aim of this study was to analyze the safety of IVT in a cohort of patients with stroke who had undergone surgery within the previous 90 days.

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