<p>Identification of Predictors for Hemorrhagic Transformation in Patients with Acute Ischemic Stroke After Endovascular Therapy Using the Decision Tree Model</p>

Abstract

Purpose This study aimed to identify independent predictors for the risk of hemorrhagic transformation (HT) in arterial ischemic stroke (AIS) patients. Methods Consecutive patients with AIS due to large artery occlusion in the anterior circulation treated with mechanical thrombectomy (MT) were enrolled in a tertiary stroke center. Demographic and medical history data, admission lab results, and Circle of Willis (CoW) variations were collected from all patients. Results Altogether, 90 patients were included in this study; among them, 34 (37.8%) had HT after MT. The final pruned decision tree (DT) model consisted of collateral score and platelet to lymphocyte ratios (PLR) as predictors. Confusion matrix analysis showed that 82.2% (74/90) were correctly classified by the model (sensitivity, 79.4%; specificity, 83.9%). The area under the ROC curve (AUC) was 81.7%. The DT model demonstrated that participants with collateral scores of 2–4 had a 75.0% probability of HT. For participants with collateral scores of 0–1, if PLR at admission was <302, participants had a 13.0% probability of HT; otherwise, participants had an 75.0% probability of HT. The final adjusted multivariate logistic regression analysis indicated that collateral score 0–1 (OR, 10.186; 95% CI, 3.029–34.248; p < 0.001), PLR (OR, 1.005; 95% CI, 1.001–1.010; p = 0.040), and NIHSS at admission (OR, 1.106; 95% CI, 1.014–1.205; p = 0.022) could be used to predict HT. The AUC for the model was 0.855, with 83.3% (75/90) were correctly classified (sensitivity, 79.4%; specificity, 87.3%). Less patients with HT achieved independent outcomes (mRS, 0–2) in 90 days (20.6% vs. 64.3%, p < 0.001). Rate of poor outcomes (mRS, 4–6) was significantly higher in patients with HT (73.5% vs. 19.6%; p < 0.001). Conclusion Both the DT model and multivariate logistic regression model confirmed that the lower collateral status and the higher PLR were significantly associated with an increased risk for HT in AIS patients after MT. PLR may be one of the cost-effective and practical predictors for HT. Further prospective multicenter studies are needed to validate our findings.

Baseline Characteristics Associated with Good Collateral Status Using Hypoperfusion Index as an Outcome

“…Additionally, the baseline Hct of patients with proximal M2 occlusions was found to be higher than those with M1 occlusions, however, the reason for this association is not clear and needs to be explored in larger studies. The HT rate within 48 H after MT was significantly higher in patients with ICA occlusions compared to M2 occlusions, which differs from prior literature where the rate of HT has been shown to be similar between ICA and MCA occlusions [ 11 ]. The reason for this may be due to the much larger volume of territory at risk in ICA occlusions compared to M2 occlusions [ 12 , 13 ].…”

Prognostic Role of the Platelet-Lymphocyte Ratio in Acute Ischemic Stroke Patients Undergoing Reperfusion Therapy: A Meta-Analysis

“…This could be attributed to previous observations that platelets can, in conjunction with neutrophils and fibrinogen, cause blood brain barrier (BBB) damage after initial occlusion and thus may predispose patients to hemorrhagic transformation. 22 We observed no statistically significant association of admission PLR with radiological bleeding and that removing Eren et al caused the effect to no longer cross the line of no effect. This was surprising, as this was the study with the longest follow-up CT scanning, extending up to 72 hours, more than twice the next highest included study.…”

“…PLR is a beneficial biomarker owing to its low cost and availability from standard blood panels, 4 , 10 and its ability to provide insight into both the hemostatic/thrombotic and inflammatory pathways underlying AIS pathogenesis. 22 It is of particular interest in patients receiving RT due to the association of platelets with increased recruitment and activation of immune cells, including neutrophils, which have a role in ischaemia–reperfusion injury (IRI), a phenomenon where stroke continues to progress despite resolution of the occlusion, along with the no-reflow phenomenon, whereby blood flow is not restored despite removal of the occlusion. The role of platelets in formation of neutrophil extracellular traps may contribute to this.…”

“…Additionally, our use of SMD to account for the continuous nature of PLR allows us to overcome the issue of varying thresholds in the published literature. We also considered admission and delayed PLR separately, using pre- and postintervention definitions, thereby accounting for the role of platelets in IRI and no-reflow injury in clinical and recanalisation outcomes and in potential BBB damage leading to HT, 22 , 38 as well as the dynamicity of immune cells in AIS pathogenesis. 4 , 10 By considering treatment modalities separately, we also clearly show that there are differences in treatment modalities, which can be used not only to determine the utility of PLR in different patient subgroups but also to guide further research.…”

“…Very few studies considered the association of dynamic PLR changes with outcomes, and thus, this could not be analysed. Finally, not all studies 12 , 13 , 17 , 22 , 34 , 35 excluded patients with active infection, malignancy, or chronic disease, which can influence lymphocyte count via systemic inflammation. 4 , 10 …”