Hemorrhage After Endovascular Recanalization in Acute Stroke: Lesion Extent, Collaterals and Degree of Ischemic Water Uptake Mediate Tissue Vulnerability

Abstract

Background and Purpose: Intracranial hemorrhage (ICH) remains a major complication of endovascular treatment (ET) in acute stroke. The aim of this study was to identify clinical and imaging predictors for ICH in patients with acute ischemic stroke undergoing successful ET. Methods: We performed a retrospective analysis of patients with large vessel occlusion in the anterior circulation who underwent successful ET at our university medical center between 2015 and 2018. ICH was diagnosed on non-enhanced CT and a binary outcome was defined: ICH occurrence in the immediate post-interventional phase within 12–36 h (yes/no). The impacts of clinical, radiological, and interventional parameters on outcome were assessed in logistic regression models. Results: One hundred and seven patients fulfilled the inclusion criteria. 37 (34.6%) showed an ICH of which 7 (6.5%) patients were diagnosed as symptomatic and 30 (28.04%) as asymptomatic. Multivariable regression analyses identified a lower ASPECTS (adjusted odds ratio (OR) 1.95, 95%CI: 1.4–3.63, P = 0.037), low collateral score (adjusted OR 0.12, 95%CI: 0.03–0.49, P = 0.003) and high Net Water Uptake (NWU) (adjusted OR 1.56, 95%CI: 2.34–1.03, P = 0.007) as independent predictors of ICH after successful ET. Conclusions: CT-based quantitative NWU, ASPECTS, and collateral score mediate tissue vulnerability and are reliable independent predictors of a bleeding event after successful ET. This imaging-based prediction model might be useful for early stratification of patients at high risk of a bleeding event after ET, especially with low ASPECTS.

Prognosis and risk factors associated with asymptomatic intracranial hemorrhage after endovascular treatment of large vessel occlusion stroke: a prospective multicenter cohort study

“…Intracranial hemorrhage is a relatively common complication after LVO recanalization, estimated at 35% in the literature with a minority of sICH (5.6%) [21]. Our results are consistent with those of other studies, where the proportion of aICH after EVT for AIS is reported to be approximately 28.0%-39.1% [22,23]. Notably, the occurrence of ICH in major EVT trials did not modify the 3-month functional benefit in the bridging arms compared to the 'IVTalone' arm [24].…”

“…Diabetes is known to be associated with ICH, but the underlying pathophysiology via hyperglycemia and cerebral microangiopathy remains poorly understood [26,27]. High baseline NIHSS score, low baseline ASPECTS and late onset to puncture are known risk factors of ICH in previous studies in IVT [28][29][30] and EVT [22,23,31]. Probably because of the hormonal impact on coagulation and associated cardiovascular risk factors, men seem to have a higher rate of aICH than women [32][33][34].…”

Endovascular Thrombectomy for Low ASPECTS Large Vessel Occlusion Ischemic Stroke: A Systematic Review and Meta-Analysis

“…[3][4][5] Low ASPECTS has been shown to predict intracranial hemorrhage after EVT. 36,37 Thus, the difference in sICH rate (9.2% vs 4.4%) is most likely accounted for by the low ASPECTS of our patients (<6) compared to the ones included in the earlier trials (mean ASPECTS of 9). [3][4][5] The previously reported 19% sICH rate in EVT patients with an ASPECTS of <6 from a subset of the HERMES collaboration 12 was not corroborated by our review that only showed a 9.2% sICH rate.…”

Lesion Age Imaging in Acute Stroke: Water Uptake in CT Versus DWI‐FLAIR Mismatch

“…10 This patientindividual variability of NWU may imply an inherent limitation to show an accurate "time clock," however, at the same time, it may imply an advantage: NWU as an imaging biomarker of actual ischemic pathophysiology has been emphasized as a patient-specific tool to estimate the real "tissue clock" of infarct progression independent of time that directly relates to functional outcome. 17,22,23 Limitations of our study include the small number of patients as well as its retrospective design. The small number is mainly due to the fact that patients with acute stroke rarely receive both imaging modalities consecutively during triage.…”

“…22 Although low NWU may be a beneficial constellation for intravenous thrombolysis, high levels of NWU may suggest higher lesion progression with subsequent higher risk for malignant edema or secondary hemorrhage. 17,23 In MRI, the presence of a visible ischemic lesion on DWI combined with the absence of a clearly visible hyperintense lesion in the same region on FLAIR may predict symptom onset within 4.5 hours. 5,10,15,24,25 This method, which is based on identifying lesions at an early stage of infarct, has been put to a clinical test in the recently published WAKE-UP trial.…”