Background and purposeHemorrhagic transformation (HT) is a complication that may cause neurological deterioration in patients with acute ischemic stroke. Various radiological subtypes of HT can be distinguished. Their influence on functional outcome is currently unclear. The purpose of this study was to assess the associations between HT subtypes and functional outcome in acute ischemic stroke patients with proven large vessel occlusion included in the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic stroke in The Netherlands).MethodsAll patients with follow-up imaging were included. HT was classified on follow-up CT scans according to the European Cooperative Acute Stroke Study II classification. Functional outcome was assessed using the modified Rankin Scale (mRS) 90 days after stroke onset. Ordinal logistic regression analysis with adjustment for potential confounders was used to determine the association of HT subtypes with functional outcome.ResultsOf 478 patients, 222 had HT. Of these, 76 (16%) patients were classified as hemorrhagic infarction type 1, 71 (15%) as hemorrhagic infarction type 2, 36 (8%) as parenchymal hematoma type 1, and 39 (8%) as parenchymal hematoma type 2. Hemorrhagic infarction type 2 (adjusted common OR (acOR) 0.54, 95% CI: 0.32 to 0.89) and parenchymal hematoma type 2 (acOR 0.37, 95% CI 0.17 to 0.78) were significantly associated with a worse functional outcome. Hemorrhagic infarction type 1 and parenchymal hematoma type 1 were not significantly associated, although their point estimates pointed in the direction of worse outcome.ConclusionThis study suggests that parenchymal hematoma type 2 is relevant for functional outcome after an acute ischemic stroke, and smaller HTs might also influence long term functional outcome.Trail registration number ISRCTN10888758.

Background and Purpose— Hemorrhagic transformation (HT) after acute ischemic stroke may cause severe neurological deterioration and affects functional outcome. Identifying patients most likely to suffer from this complication could potentially be used for future treatment selection. Reperfusion after endovascular therapy could be associated with different risk factors for HT than intravenous thrombolytics as these treatments largely differ. In this study, we aimed to identify clinical and imaging markers that are associated with HT subtypes in the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) population. Methods— In this post hoc analysis, all patients with follow-up imaging were included. HT was classified according to ECASS II (European Cooperative Acute Stroke Study). Variables with an association of P <0.1 were included in the multivariable logistic regression to identify clinical and radiological variables associated with petechial hemorrhagic infarction, parenchymal hematoma (PH), and symptomatic intracranial hemorrhage. Results— Of the 478 out of 500 included patients in this subanalysis, 46% had HT (n=222). Of these, 66% had hemorrhagic infarction (n=147) and 34% PH (n=75). Symptomatic intracranial hemorrhage was observed in 7.3% (n=35) of all patients. Baseline National Institutes of Health Stroke Scale (odds ratio [OR], 1.05,95% CI, 1.01–1.09 per point) and absent/poor collaterals (OR, 1.90; 95% CI, 1.05–3.42) were significantly associated with hemorrhagic infarction. Increased systolic blood pressure (OR, 1.17; 95% CI, 1.05–1.31 per 10 mm Hg) and atrial fibrillation (OR, 1.94; 95% CI, 1.08–3.48) were associated with PH. Increased systolic blood pressure (OR, 1.28; 95% CI, 1.12–1.48) and antiplatelet use (OR, 2.6; 95% CI, 1.08–6.3) were associated with symptomatic intracranial hemorrhage. Conclusions— Clinical and imaging stroke severity parameters were associated with HT, both in hemorrhagic infarction and PH, whereas baseline patients characteristics like systolic blood pressure, atrial fibrillation, and antiplatelet use were only associated with PH or symptomatic intracranial hemorrhage. Clinical Trial Registration— URL: http://www.controlled-trials.com . Unique identifier: ISRCTN10888758.

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

BackgroundIntracranial hemorrhage (ICH) is a frequent complication after endovascular stroke treatment.ObjectiveTo assess the association of the occurrence and type of ICH after endovascular treatment (EVT) with functional outcome.MethodsWe analyzed data from the MR CLEAN-NO IV and MR CLEAN-MED trials. Both trials included adult patients with ischemic stroke with a large vessel occlusion in the anterior circulation, who were eligible for EVT. ICH was classified (1) as asymptomatic or symptomatic (concomitant neurological deterioration of ≥4 points on the NIHSS, or ≥2 points on 1 NIHSS item), and (2) according to the Heidelberg Bleeding Classification. We used multivariable ordinal logistic regression analyses to assess the association of the occurrence and type of ICH with the modified Rankin Scale score at 90 days.ResultsOf 1017 included patients, 331 (33%) had an asymptomatic ICH, and 90 (9%) had a symptomatic ICH. Compared with no ICH, both asymptomatic (adjusted common OR (acOR)=0.76; 95% CI 0.58 to 0.98) and symptomatic (acOR=0.07; 95% CI 0.04 to 0.14) ICH were associated with worse functional outcome. In particular, isolated parenchymal hematoma type 2 (acOR=0.37; 95% CI 0.14 to 0.95), combined parenchymal hematoma with hemorrhage outside infarcted brain tissue (acOR=0.17; 95% CI 0.10 to 0.30), and combined hemorrhages outside infarcted brain tissue (acOR=0.14; 95% CI 0.03 to 0.74) were associated with worse functional outcome than no ICH.Strength of the association of ICH with functional outcome depends on the type of ICH. Although the association is stronger for symptomatic ICH, asymptomatic ICH after EVT is also associated with worse functional outcome.

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