Intracerebral hemorrhage secondary to intravenous and endovascular intraarterial revascularization therapies in acute ischemic stroke: an update on risk factors, predictors, and management

Mokin, Maxim; Kan, Peter; Kass‐Hout, Tareq; Abla, Adib A.; Dumont, Travis M.; Snyder, Kenneth V.; Hopkins, L. Nelson; Siddiqui, Adnan H.; Levy, Elad I.

doi:10.3171/2012.1.focus11352

Cited by 54 publications

(38 citation statements)

References 55 publications

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“…1 The pathophysiology of cerebral hemorrhage associated with reperfusion therapies involves the disruption of the BBB, procedure-related direct vessel damage, and the toxicity secondary to thrombolytic drugs. 22 In our series, the presence of signs of BBB disruption in DE-CT was associated with longer duration of the procedures and higher number of thrombectomy device passes, as well as with preintervention stroke severity and longer duration of ischemia. Longer procedure times were highly correlated with the number of passes of thrombectomy devices, as a marker of direct procedure-related vessel damage, and probably with enhanced exposure to intra-arterial contrast.…”

Section: Discussionmentioning

confidence: 78%

“…68 (13) 29 (43) 18 (27) 45 (67) 20 (30) 31 (46) 23 (34) 36 (54) 153 (23) 127 (113-155) 16 (13)(14)(15)(16)(17)(18)(19)(20)(21)(22) 8 (7)(8)(9) 31 (46) 36 (54) 277 47 50 ( (22) 27 (46) 9 (15) 25 (42) 15 (25) 22 (37) 141 (24) 119 (101-135) 13 (9)(10)(11)(12)(13)(14)(15)(16)(17)(18) 44 (75) 41 (70) 18 (31) 263 300 30 Poor outcome p N=50 69 (12.3) 20 (40) 12 (24) 34 (68) 17 (34) 24 (48) 17 (34) 26 …”

Section: Poor Outcome P N=67unclassified

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Relevance of Blood–Brain Barrier Disruption After Endovascular Treatment of Ischemic Stroke

Renú¹,

Amaro²,

Laredo³

et al. 2015

Stroke

106

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E ndovascular therapy (ET) is an increasingly used therapeutic strategy in acute ischemic stroke.1 The administration of contrast material during ET often results in high attenuation areas on postprocedural brain computed tomography (CT) related to blood-brain barrier (BBB) breakdown, although their clinical significance is conflicting.2-8 Early differentiation between contrast enhancement and brain hemorrhage may be of assistance to detect bleeding complications and anticipate the start of antithrombotic therapy after thrombolysis. 9 However, in the early post-ET period, this distinction is not feasible using conventional post-treatment CT. [2][3][4][5]10 Dual-energy CT (DE-CT) is a relatively new technique that allows for a reliable differentiation between tissue high attenuation areas related to iodine contrast material extravasation and parenchymal hemorrhage.11-13 The technique is based on the different attenuation effects of normal brain tissue, iodine, and blood at different irradiation energy levels. In patients receiving ET, DE-CT has shown a good accuracy for early differentiation between hemorrhage and contrast extravasation, but these studies did not address specifically the prognostic implications of this segregation. 12,14,15 Brain ischemia induces time-dependent changes in microvascular integrity and these changes may lead to the extravasation of contrast molecules and cellular blood elements from microvessels leading to hemorrhagic complications. 16,17 Thus, the ability of DE-CT to differentiate between contrast and brain hemorrhage after ET may allow discriminating between different grades BBB disruption. The aim of the study was to evaluate the prognostic significance of the presence of contrast Background and Purpose-Computed tomographic (CT) high attenuation (HA) areas after endovascular therapy for acute ischemic stroke are a common finding indicative of blood-brain barrier disruption. Dual-energy CT allows an accurate differentiation between HA areas related to contrast staining (CS) or to brain hemorrhage (BH). We sought to evaluate the prognostic significance of the presence of CS and BH after endovascular therapy. Methods-A prospective cohort of 132 patients treated with endovascular therapy was analyzed. According to dual-energy CT findings, patients were classified into 3 groups: no HA areas (n=53), CS (n=32), and BH (n=47). The rate of new hemorrhagic transformations was recorded at follow-up neuroimaging. Clinical outcome was evaluated at 90 days with the modified Rankin Scale (poor outcome, 3-6). Results-Poor outcome was associated with the presence of CS (odds ratio [OR], 11.3; 95% confidence interval, and BH (OR, 10.4; 95% confidence interval,

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Section: Discussionmentioning

confidence: 78%

Section: Poor Outcome P N=67unclassified

Relevance of Blood–Brain Barrier Disruption After Endovascular Treatment of Ischemic Stroke

Renú¹,

Amaro²,

Laredo³

et al. 2015

Stroke

106

View full text Add to dashboard Cite

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“…5,6 Of those mechanisms, the severity of brain ischemia can be reliably quantified using dynamic contrast-enhanced magnetic resonance imaging (MRI) or computerized tomography (CT) by measuring cerebral blood flow (CBF), cerebral blood volume (CBV) or time-based variables such as Tmax, mean transit time (MTT), time to peak (TTP) or delay time (DT). MRI-based clinical studies of patients with acute stroke treated or not with thrombolysis have shown that very severe reductions of CBV (termed as Very Low CBV) are strongly associated with the risk of PH, [7][8][9] particularly when delayed reperfusion occurs after thrombolysis.…”

Section: Introductionmentioning

confidence: 99%

Brain hemorrhage after endovascular reperfusion therapy of ischemic stroke: a threshold-finding whole-brain perfusion CT study

Renú

Laredo

Tudela

et al. 2016

J Cereb Blood Flow Metab

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Endovascular reperfusion therapy is increasingly used for acute ischemic stroke treatment. The occurrence of parenchymal hemorrhage is clinically relevant and increases with reperfusion therapies. Herein we aimed to examine the optimal perfusion CT-derived parameters and the impact of the duration of brain ischemia for the prediction of parenchymal hemorrhage after endovascular therapy. A cohort of 146 consecutive patients with anterior circulation occlusions and treated with endovascular reperfusion therapy was analyzed. Recanalization was assessed at the end of reperfusion treatment, and the rate of parenchymal hemorrhage at follow-up neuroimaging. In regression analyses, cerebral blood volume and cerebral blood flow performed better than Delay Time maps for the prediction of parenchymal hemorrhage. The most informative thresholds (receiver operating curves) for relative cerebral blood volume and relative cerebral blood flow were values lower than 2.5% of normal brain. In binary regression analyses, the volume of regions with reduced relative cerebral blood volume and/or relative cerebral blood flow was significantly associated with an increased risk of parenchymal hemorrhage, as well as delayed vessel recanalization. These results highlight the relevance of the severity and duration of ischemia as drivers of blood-brain barrier disruption in acute ischemic stroke and support the role of perfusion CT for the prediction of parenchymal hemorrhage.

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“…Since we evaluated the effectiveness of endovascular treatment on the top of standard therapy, this finding is not surprising and may be linked to the reperfusion of the ischemic area, in which there is a blood-brain-barrier alteration triggered by ischemia [29]. On the other hand, like in most reperfusion studies in stroke patients, this increased risk did not offset the positive effect of the treatment.…”

Section: Discussionmentioning

confidence: 85%

Endovascular Treatment over Standard Medical Therapy in Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

Cerrone¹

2015

Cardiovasc Pharm Open Access

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Background: Endovascular treatment plays a continuously expanding role in the treatment of acute ischemic stroke. Several randomized controlled clinical trials evaluating possible benefits of endovascular therapy were conducted. From these trials emerged conflicting results. The aim of this study was to evaluate the efficacy of endovascular treatment over standard therapy in acute ischemic stroke. Methods:We searched in PubMed and EMBASE databases from the date of inception until 2015/07/31. The primary outcome was the functional neurological outcome at 90 days measured with modified Rankin Score ≤ 2. Secondary outcomes were partial or complete recanalization, assessed with modified arterial occlusive lesion, thrombolysis in myocardial infarction or thrombolysis in cerebral infarction scores of 2-3 and mortality. Safety outcome was Symptomatic Intracranial Hemorrhage (SICH). Data were pooled in the control and intervention groups, and odds ratios were calculated with 95% interval confidence. Statistical heterogeneity was evaluated with the χ 2 Mantel-Haenszel method and I₂ method. A p value <0.05 was considered statistically significant. Heterogeneity was considered significant for P values <0.10.Results: 12 trials were included with 2725 participants. Compared with standard therapy, endovascular treatment significantly improved the outcome at 90 days (OR: 1.77; 95% CI: 1.51-2.08). This result was affected by a significative heterogeneity. After a sensitivity analysis, excluding the trials in which the demonstration of large vessel occlusion was not an inclusion criterion, primary outcome was improved in the intervention group (OR: 2.05 95% CI: 1.70-2.46), with non-significant heterogeneity. The recanalization rate was higher and mortality was lower in the intervention groups, but these differences were not significant. The proportion of SICH was marginally higher in the intervention groups, again without any statistical significance. Conclusion:Endovascular treatment for acute ischemic stroke ensures a significant increase of patients with favorable outcome compared with standard therapy in the absence of risk. Vascular studies before treatment are mandatory. related to systemic concentration of thrombolytic agents [4]. Patients out of time window or with contraindications to intravenous thrombolysis, could be eligible for primary endovascular treatment [5]. On the other hand endovascular treatment is not free of complications. The procedure could require general anesthesia, which can increase the risk of in-hospital mortality [6], and can cause catheter-related complications. Another factor to consider is the need for an experienced interventional neuroradiology team, not available in all stroke centers. Endovascular treatment benefits have been debated in the last years. Several Randomized Controlled Trials (RCT), comparing endovascular treatments versus standard therapy have been conducted, but these studies showed conflicting results. The wide differences between these RCTs and the relatively small ...

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Intracerebral hemorrhage secondary to intravenous and endovascular intraarterial revascularization therapies in acute ischemic stroke: an update on risk factors, predictors, and management

Cited by 54 publications

References 55 publications

Relevance of Blood–Brain Barrier Disruption After Endovascular Treatment of Ischemic Stroke

Relevance of Blood–Brain Barrier Disruption After Endovascular Treatment of Ischemic Stroke

Brain hemorrhage after endovascular reperfusion therapy of ischemic stroke: a threshold-finding whole-brain perfusion CT study

Endovascular Treatment over Standard Medical Therapy in Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials

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