Saccular aneurysms should not contraindicate thrombolysis, data suggest

IV thrombolysis appeared safe among patients who had acute ischemic stroke with saccular unruptured intracranial aneurysms, according to results of a prospective cohort study published in Neurology.

“Great strides have been made to offer IV thrombolysis to as many acute stroke patients as possible,” Jyri Juhani Virta, MD, PhD, of the department of neurosurgery at Helsinki University Hospital and University of Helsinki in Finland, told Healio Neurology. “Because of lacking data, especially large intracranial aneurysms have been considered a contraindication for thrombolysis. We aimed to clarify this topic.”

Virta and colleagues analyzed data of 3,953 consecutive patients who received IV thrombolysis treatment at a comprehensive stroke center between 2005 and 2019. They examined radiology reports and records at the Finnish Care Register for Health Care to pinpoint patients with unruptured intracranial aneurysms (UIAs) among all patients with acute ischemic stroke treated with IV thrombolysis at the center. Further, they evaluated patient angiograms for aneurysm characteristics and other brain imaging studies for intracranial hemorrhages following IV thrombolysis.

In-hospital intracranial hemorrhages linked to a UIA rupture following IV thrombolysis served as the main outcome. In-hospital symptomatic intracranial hemorrhages according to NIH Stroke Scale score increases of four points or more and any in-hospital intracranial hemorrhages served as secondary outcomes.

Results showed 155 UIAs (141 saccular and 14 fusiform) occurred among 132 (3.3%) patients. The UIAs had a mean diameter of 4.7 ± 3.8 mm, of which 18.7% were 7 mm or larger and 9.7% were 10 mm or larger in diameter. No saccular UIAs ruptured after IV thrombolysis. Three (2.3%) patients with large, fusiform basilar artery UIAs had a fatal rupture at 27 hours, 43 hours and 19 days after IV thrombolysis. These patients received anticoagulation treatments after IV thrombolysis, with anticoagulation occurring during the UIA rupture. Researchers detected any and symptomatic intracranial hemorrhages among 18.9% (95% CI, 12.9-26.2) and 8.3% (95% CI, 4.4-13.8) of all patients with acute ischemic stroke, respectively.

According to Virta, results of previous studies and the current study suggest thrombolysis is safe for patients with saccular aneurysms.

“I believe that saccular aneurysms should not be considered a contraindication for thrombolysis,” Virta said. “In contrast, large fusiform aneurysms can rupture after thrombolysis if the patients are treated with anticoagulants as well.

“Overall, patients with such unstable aneurysms pose a clinical dilemma and treatment should be optimized individually for every such patient,” Virta said.