Predictors of Symptomatic Intracranial Hemorrhage after Endovascular Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Abstract

<b><i>Introduction:</i></b> This meta-analysis assessed the predictors of symptomatic intracranial hemorrhage (sICH) after endovascular thrombectomy (EVT) for patients with acute ischemic stroke. <b><i>Methods:</i></b> PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science were searched for studies published from inception to February 16, 2021. We included studies that evaluated the predictors of sICH after EVT. The random-effect model or fixed-effect model was used to pool the estimates according to the heterogeneity. <b><i>Results:</i></b> A total of 25 cohort studies, involving 15,324 patients, were included in this meta-analysis. The total incidence of sICH was 6.72 percent. Age (MD = 2.57, 95% CI: 1.53–3.61; <i>p</i> < 0.00001), higher initial NIHSS score (MD = 1.71, 95% CI: 1.35–2.08, <i>p</i> < 0.00001), higher initial systolic blood pressure (MD = 7.40, 95% CI: 5.11–9.69, <i>p</i> < 0.00001), diabetes mellitus (OR = 1.36, 95% CI: 1.10–1.69, <i>p</i> = 0.005), poor collaterals (OR = 3.26, 95% CI: 2.35–4.51; <i>p</i> < 0.0001), internal carotid artery occlusion (OR = 1.55, 95% CI: 1.26–1.90; <i>p</i> < 0.0001), longer procedure time (MD = 18.92, 95% CI: 11.49–26.35; <i>p</i> < 0.0001), and passes of retriever >3 (OR = 3.39, 95% CI: 2.45–4.71; <i>p</i> < 0.0001) were predictors of sICH, while modified thrombolysis in cerebral infarction score ≥2b (OR = 0.61, 95% CI: 0.46–0.79; <i>p</i> = 0.0002) was associated with a decreased risk of sICH. There were no significant differences in the female gender, initial serum glucose, initial ASPECT score, atrial fibrillation, oral anticoagulants, antiplatelet therapy, intravenous thrombolysis, general anesthesia, neutrophil-to-lymphocyte ratio, and emergent stenting. <b><i>Conclusions:</i></b> This study identified many predictors of sICH. Some of the results lack robust evidence given the limitations of the study. Therefore, larger cohort studies are needed to confirm these predictors.

Efficacy of Endovascular Thrombectomy in Acute Basilar Artery Occlusion with Low PC‐ASPECTS: A Nationwide Prospective Registry‐Based Study

“…Of the patients, 40.3% (n = 228) had a cardioembolic stroke and 29.9% (n = 169) had a large artery atherosclerotic stroke; 16.6% (n = 94) had a tandem occlusion of the vertebral and basilar arteries. The median initial NIHSS score was 19 (9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25), and the median score on the PC-ASPECTS was 5 (3)(4)(5)(6); 32.0% of the patients received IVT. After propensity score matching and weighting utilizing IPTW, the balance of the covariates significantly improved, as shown in Table 1.…”

“…sICH is generally more frequent in anterior circulation strokes, with rates ranging from 6.7% to 16% depending on the definition, type, and treatment modalities of the stroke. [20][21][22][23] The occurrence of sICH in anterior circulation stroke has been found to be associated with several factors, including high systolic blood pressure, poor collaterals, a higher number of stent retriever passages, and longer procedure time. 23 The differences between clinical trials conducted in the Chinese population and the present study using the Korean population are not yet fully understood.…”

“…[20][21][22][23] The occurrence of sICH in anterior circulation stroke has been found to be associated with several factors, including high systolic blood pressure, poor collaterals, a higher number of stent retriever passages, and longer procedure time. 23 The differences between clinical trials conducted in the Chinese population and the present study using the Korean population are not yet fully understood. The welldeveloped collateral circulation in the posterior circulation may prevent the progression of the penumbra into the infarct core and reduce the risk of hemorrhagic transformation after EVT.…”

“…However, we found a lower rate of sICH (2.6%–2.9%) with no significant difference between the EVT and conservative treatment groups. sICH is generally more frequent in anterior circulation strokes, with rates ranging from 6.7% to 16% depending on the definition, type, and treatment modalities of the stroke 20–23 . The occurrence of sICH in anterior circulation stroke has been found to be associated with several factors, including high systolic blood pressure, poor collaterals, a higher number of stent retriever passages, and longer procedure time 23 .…”

Effect of concomitant usage of alteplase and mechanical thrombectomy for M1 middle cerebral artery occlusion on clinical outcome: a retrospective analysis of 457 patients from two centers

“…Known predictors for ICH after concomitant alteplase and EVT administration are higher initial National Institutes of Health Stroke Score (NIHSS), higher initial systolic blood pressure, diabetes mellitus, poor collaterals, internal carotid artery occlusion, longer procedure time, and passes of retriever >3, and modified thrombolysis in cerebral infarction score ≥ 2b was associated with a decreased risk of sICH ( 13 ).…”