IER-SICH Nomogram to Predict Symptomatic Intracerebral Hemorrhage After Thrombectomy for Stroke

Nomogram-Based Prediction of 3-Month Unfavorable Outcome and Early Neurological Deterioration After Endovascular Thrombectomy in Acute Ischemic Stroke

Background

Some acute ischemic stroke (AIS) patients due to large-vessel occlusion, who underwent endovascular thrombectomy (EVT), continue to experience unfavorable outcomes. Furthermore, the impact of internal carotid artery (ICA) tortuosity remains uncertain. This study aimed to determine the value of ICA tortuosity and clinical features in predicting 3-month unfavorable outcome and early neurological deterioration (END) after EVT in AIS patients through nomograms.

Methods

A total of 313 AIS patients treated with EVT at the First Affiliated Hospital of Xi'an Jiaotong University were retrospectively analyzed and randomized into two cohorts: training cohort (n=219) and validation cohort (n=94). After the selection of relevant features, nomograms for predicting the 3-month unfavorable outcome (mRS > 2) and END (an increase in NIHSS score of ≥4 within 24 hours) were established. The predictive accuracy of the nomograms was evaluated using ROC curves, calibration plots, and decision curve analysis (DCA).

Results

Among 313 patients, ICA tortuosity was observed in 19.50% (extracranial) and 21.10% (cavernous) of patients. Furthermore, 53.30% of patients experienced a 3-month unfavorable outcome, while END occurred in 15.70%. The independent predictors for the 3-month unfavorable outcome included age, NIHSS score, puncture-to-recanalization time, eTICI score, and blood glucose. The addition of two tortuosity features (extracranial and cavernous ICA tortuosity) resulted in a significant improvement in model differentiation. The nomogram that included ICA tortuosity achieved an AUC of 0.826 and 0.803 in the training and validation cohorts. ASPECT score, occlusion site, number of retriever passes, and blood glucose were identified as factors associated with END. The AUC was 0.770 and 0.772 in the training and validation cohorts. However, the incorporation of ICA tortuosity did not significantly enhance the model for predicting END.

Conclusion

ICA tortuosity characteristics significantly improve the discrimination of the nomogram model in predicting the 3-month unfavorable outcome. This can be used as guidance in clinical decision-making.

Traditional and machine learning models for predicting haemorrhagic transformation in ischaemic stroke: a systematic review and meta-analysis

BACKGROUND

Haemorrhagic transformation (HT) is a severe complication after ischaemic stroke, but identifying patients at high risks remains challenging. Although numerous prediction models have been developed for HT following thrombolysis, thrombectomy, or spontaneous occurrence, a comprehensive summary is lacking. This study aimed to review and compare traditional and machine learning-based HT prediction models, focusing on their development, validation, and diagnostic accuracy.

METHODS

PubMed and Ovid-Embase were searched for observational studies or randomised controlled trials related to traditional or machine learning-based models. Data were extracted according to Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS) checklist and risk of bias was assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). Performance data for prediction models that were externally validated at least twice and showed low risk of bias were meta-analysed.

RESULTS

A total of 100 studies were included, with 67 focusing on model development and 33 on model validation. Among 67 model development studies, 44 were traditional model studies involving 47 prediction models (with National Institutes of Health Stroke Scale score being the most frequently used predictor in 35 models), and 23 studies focused on machine learning prediction models (with support vector machines being the most common algorithm, used in 10 models). The 33 validation studies externally validated 34 traditional prediction models. Regarding study quality, 26 studies were assessed as having a low risk of bias, 11 as unclear, and 63 as high risk of bias. Meta-analysis of 15 studies validating eight models showed a pooled area under the receiver operating characteristic curve of approximately 0.70 for predicting HT.

CONCLUSION

While significant progress has been made in developing HT prediction models, both traditional and machine learning-based models still have limitations in methodological rigour, predictive accuracy, and clinical applicability. Future models should undergo more rigorous validation, adhere to standardised reporting frameworks, and prioritise predictors that are both statistically significant and clinically meaningful. Collaborative efforts across research groups are essential for validating these models in diverse populations and improving their broader applicability in clinical practice.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (CRD42022332816).

Predicting symptomatic intracranial hemorrhage after endovascular treatment of vertebrobasilar artery occlusion: PEACE score

BACKGROUND

Current clinical decision tools for assessing the risk of symptomatic intracranial hemorrhage (sICH) in patients with vertebrobasilar artery occlusion (VBAO) who received endovascular treatment (EVT) have limited performance. This study develops and validates a clinical risk score to precisely estimate the risk of sICH in VBAO patients.

METHODS

The derivation cohort recruited patients with VBAO who received EVT from the Posterior Circulation IschemIc Stroke Registry in China. Based on the posterior circulation-Alberta Stroke Program Early CT Score (pc-ASPECTS) evaluation method, the cohort was further divided into non-contrast CT (NCCT) and diffusion weighted imaging (DWI) cohorts to construct predictive models. sICH was diagnosed according to the Heidelberg Bleeding Classification within 48 hours of EVT. Clinical signature was constructed in the derivation cohort using machine learning and was validated in two additional cohorts from Asia and Europe.

RESULTS

We enrolled 1843 patients who underwent EVT and had complete data. pc-ASPECTS of 1710 patients was evaluated on NCCT and 699 patients on DWI. In the NCCT cohort, 1364 individuals made up the training set, of whom 101 (7.4%) developed sICH. In the DWI cohort, the training set consisted of 560 individuals, with 44 (7.9%) experiencing sICH. Predictors of sICH were: glucose, pc-ASPECTS, time from estimated occlusion to groin puncture (EOT), poor collateral circulation, and modified Thrombolysis in Cerebral Infarction (mTICI) score. From these predictors, we derived the weighted poor collateral circulation-EOT-pc-ASPECTS-mTICI-glucose (PEACE) score. The PEACE score showed good discrimination in the training set (area under the curve (AUC)NCCT=0.85; AUCDWI=0.86), internal validation set (AUCNCCT=0.81; AUCDWI=0.82), and two additional external validation set (Asia: AUCNCCT=0.78, AUCDWI=0.80; Europe: AUCNCCT=0.74, AUCDWI=0.78).

CONCLUSION

The PEACE score reliably predicted the risk of sICH in VBAO patients who underwent EVT.

Failure of early neurological improvement can predict futile recanalization after successful interventional recanalization of anterior circulation tandem lesions

PURPOSE

To explore whether the failure of early neurological improvement can predict futile recanalization after successful interventional recanalization of anterior circulation tandem lesions.

PATIENTS AND METHODS

A retrospective analysis was conducted on the clinical data of patients who received successful interventional recanalization treatment of anterior circulation tandem lesions from January 2019 to November 2023. The failure of early neurological improvement is defined as a decrease of less than 4 points in NIHSS score compared to preoperative score at 24 h after surgery. Statistical analysis was conducted using SPSS 26.0 software, and a forest plot and Receiver Operating Characteristic curve related to futile recanalization were drawn.

RESULTS

A total of 120 patients received successful interventional recanalization of anterior circulation tandems lesion were included, including 68 cases of futile recanalization (56.67 %) and 52 cases of effective recanalization (43.33 %). The rate of failure of early neurological improvement in the futile recanalization group was higher than that in the effective recanalization group (94.12 % vs 34.62 %, P < 0.001). After adjusting for confounding factors, the rate of failure of early neurological improvement in the futile recanalization group was higher than that in the effective recanalization group (adjusted OR: 39.925; 95 % CI: 4.110-387.864; P = 0.001). The area under the Receiver Operating Characteristic curve using failure of neurological improvement for predicting futile recanalization was 0.800.

CONCLUSION

Failure of early neurological improvement is an effective indicator for predicting futile recanalization after successful interventional recanalization in anterior circulation tandem lesions.

Endovascular thrombectomy with or without intravenous alteplase in large-core ischemic stroke: a systematic review and meta-analysis

The role of bridging intravenous thrombolysis (IVT) with alteplase before endovascular thrombectomy (EVT) in treating large core ischemic stroke remains uncertain. We aimed to compare clinical outcomes and safety of EVT with or without bridging IVT in patients with anterior circulation large vessel occlusion (ACLVO) and baseline Alberta Stroke Program Early CT Score (ASPECTS) ≤ 5. We systematically searched PubMed, Web of Science, Cochrane Library, and Embase from inception until November 2023. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] 0-2). Secondary outcomes included 90-day independent ambulation (mRS 0-3), successful recanalization, any intracranial hemorrhage (ICH), symptomatic ICH (sICH) and 90-day mortality. A random-effects model was used for data pooling. Five high-quality studies, incorporating 2124 patients (41% treated with bridging IVT), were included. Across both unadjusted and adjusted analyses, no significant differences were found between the bridging IVT and EVT-alone groups in terms of functional independence (odds ratios [OR] = 1.36, 95% confidence interval [CI]: 0.90-2.07, P = 0.14; adjusted OR [aOR] = 1.19, 95% CI: 0.68-2.09, P = 0.53) or independent ambulation (OR = 1.14, 95% CI: 0.80-1.62, P = 0.47; aOR = 1.18, 95% CI: 1.00-1.39, P = 0.05) at 90 days. Furthermore, no differences were observed in successful recanalization, any ICH, sICH, and 90-day mortality between the two treatment groups. Bridging IVT exhibits similar functional and safety outcomes compared to EVT alone in ACLVO patients with baseline ASPECTS ≤ 5. Further research is warranted to confirm these findings.

Predictors of symptomatic intracerebral hemorrhage after endovascular treatment for acute ischemic stroke due to tandem lesion in anterior circulation

BACKGROUND

Endovascular treatment (EVT) of tandem lesion (TL) in the anterior circulation acute ischemic stroke (IS) usually requires periprocedural antithrombotic treatment and early initiation of dual antiplatelet therapy (DAPT) after carotid stenting. However, it may contribute to an occurrence of symptomatic intracerebral hemorrhage (SICH) in some cases. We investigated factors influencing the SICH occurrence and assessed the possible predictors of SICH after EVT.

METHODS

IS patients with TL in the anterior circulation treated with EVT were enrolled in the multicenter retrospective ASCENT study. A good three-month clinical outcome was scored as 0-2 points in modified Rankin Scale (mRS) and recanalization using the TICI scale. SICH was assessed using the SITS-MOST criteria. Logistic regression analysis was used for the assessment of possible predictors of SICH with adjustment for potential confounders.

RESULTS

In total, 300 (68.7 % males, mean age 67.3 ± 10.2 years) patients with median of admission NIHSS 17 were analyzed. Recanalization (TICI 2b-3) was achieved in 290 (96.7 %) patients and 176 (58.7 %) had mRS 0-2. SICH occurred in 25 (8.3 %) patients. Patients with SICH did not differ from those without SICH in the rate of periprocedural antithrombotic treatment (64 vs. 57.5 %, p = 0.526) and in the rate of DAPT started within the first 12 h after EVT (20 vs. 42.2 %, p = 0.087). After adjustment, admission NIHSS and admission glycemia were found as the only predictors of SICH after EVT.

CONCLUSION

Admission NIHSS and glycemia were found as the only predictors of SICH after EVT for TL. No associations between periprocedural antithrombotic treatment, early start of DAPT after EVT and SICH occurrence were found.

Intracranial hemorrhage risk in patients with cerebral microbleeds after mechanical thrombectomy for acute ischemic stroke: a systematic review and meta-analysis

Background and purpose intracranial hemorrhage risk in patients with cerebral microbleeds (CMBs) after mechanical thrombectomy for acute ischemic stroke (AIS) was investigated. We searched PubMed and Embase from inception to 29 August 2023 for relevant studies, calculated pooled odds ratio (ORs) of intracerebral hemorrhage (ICH) subtypes in AIS patients with CMB presence, 1-4 or ≥ 5 CMBs versus CMB absence, and with different CMB locations after mechanical thrombectomy. ICH subtypes included any ICH, symptomatic and asymptomatic ICH, hemorrhage outside infarct (including subarachnoid hemorrhage), hemorrhagic infarction, and parenchymal hemorrhage after mechanical thrombectomy. Five eligible studies enrolling 2051 patients were included. No significant association was shown between CMB locations (lobar, deep, infratentorial or mixed) and ICH risk. CMB presence or 1-4 CMBs did not significantly increase the risk of any ICH, symptomatic or asymptomatic ICH, ICH outside infarct, subarachnoid hemorrhage, hemorrhagic infarction, or parenchymal hemorrhage. CMBs ≥ 5 increased the risk of any ICH (OR 2.58, 95% CI 1.16-5.72), parenchymal hemorrhage (OR 3.38, 95% CI 1.43-7.97) and parenchymal hemorrhage-2 (OR 5.33, 2.05-13.86), without increasing hemorrhagic infarction or parenchymal haemorrhage-1 risk. After adjusted for possible confounding factors, increases in CMB burden were associated with hemorrhagic complications but not with symptomatic ICH. In AIS patients who received mechanical thrombectomy, no association was shown between CMB location and ICH risk. ICH risk was not significantly increased by CMB presence or 1-4 CMBs. ICH risk in patients with ≥ 5 CMBs requires further study.

Predicting symptomatic intracranial hemorrhage in anterior circulation stroke patients with contrast enhancement after thrombectomy: the CAGA score

BACKGROUND

The aim of the study was to establish a reliable scoring tool to identify the probability of symptomatic intracranial hemorrhage (sICH) in anterior circulation stroke patients with contrast enhancement (CE) on brain non-contrast CT (NCCT) after endovascular thrombectomy (EVT).

METHODS

We retrospectively reviewed consecutive patients with acute ischemic stroke (AIS) who had CE on NCCT immediately after EVT for anterior circulation large vessel occlusion (LVO). We used the Alberta stroke program early CT score (ASPECTS) scoring system to estimate the extent and location of CE. Multivariable logistic regression was performed to derive an sICH predictive score. The discrimination and calibration of this score were assessed using the area under the receiver operator characteristic curve, calibration curve, and decision curve analysis.

RESULTS

In this study, 194 of 322 (60.25%) anterior circulation AIS-LVO patients had CE on NCCT. After excluding 85 patients, 109 patients were enrolled in the final analysis. In multivariate regression analysis, age ≥70 years (adjusted OR (aOR) 9.23, 95% CI 2.43 to 34.97, P＜0.05), atrial fibrillation (AF) (aOR 4.17, 95% CI 1.33 to 13.12, P＜0.05), serum glucose ≥11.1 mmol/L (aOR 9.39, 95% CI 2.74 to 32.14, P＜0.05), CE-ASPECTS ＜5 (aOR 3.95, 95% CI 1.30 to 12.04 P＜0.05), and CE at the internal capsule (aOR 3.45, 95% CI 1.03 to 11.59, P＜0.05) and M1 region (aOR 3.65, 95% CI 1.13 to 11.80, P＜0.05) were associated with sICH. These variables were incorporated as the CE-age-glucose-AF (CAGA) score. The CAGA score demonstrated good discrimination and calibration in this cohort, as well as the fivefold cross validation.

CONCLUSION

The CAGA score reliably predicted sICH in patients with CE on NCCT after EVT treatment.

Increased Neuron-Specific Enolase Level Predicts Symptomatic Intracranial Hemorrhage in Patients with Ischemic Stroke Treated with Endovascular Treatment

BACKGROUND

Neuron-specific enolase (NSE), which is a highly specific marker for neurons, could be a predictor for prognosis in patients with symptomatic intracranial hemorrhage (sICH) with acute ischemic stroke who are receiving endovascular treatment (EVT). This study aimed to investigate the relationship between NSE and sICH in patients with acute anterior circulation stroke undergoing EVT.

METHODS

A total of 215 consecutive patients with acute stroke treated with EVT were included. Patients with stroke and acute anterior circulation occlusion, receiving EVT treated at our hospital, were enrolled between January 2017 and August 2021. NSE level was measured on arrival at the neurology intensive care unit after EVT. The patients were divided into 2 groups according to whether sICH was present. Univariate and multivariate analyses were performed. NSE level was also incorporated into the TAG score (modified Thrombolysis in Cerebral Infarction score, Alberta Stroke Program Early CT Score, and glucose level), which was developed as a scoring system to predict sICH, and the prediction capability was compared with the TAG score alone. Causal inference was performed using the package DoWhy in Python to evaluate the causal relationship between NSE and sICH.

RESULTS

The area under the curve (AUC) value of NSE showed moderate accuracy, with an AUC value of 0.729 (95% confidence interval, 0.655-0.795; P < 0.001). The NSE cutoff value was set at 23.88 ng/mL. When the NSE level ≥23.88 ng/mL, the sensitivity was 58.33% and the specificity was 78.72% (P < 0.001). The AUC for the TAG + NSE score was 0.801 compared with an AUC of 0.632 for the TAG score (Z = 2.034; P = 0.042). A causal inference model using the DoWhy library shows a proportional relationship between NSE and the diagnosis of sICH.

CONCLUSIONS

This study is the first to show that increased NSE level is an independent predictor of sICH in patients with acute anterior circulation stroke who are undergoing endovascular treatment.

Endovascular thrombectomy in young patients with stroke

BACKGROUND

Endovascular treatment (ET) is standard of care in patients with acute ischemic stroke due to large vessel occlusion, but data on ET in young patients remain limited.

AIM

We aim to compare outcomes for young stroke patients undergoing ET in a matched cohort.

METHODS

We analyzed patients from an observational multicenter cohort with acute ischemic stroke and ET, the German Stroke Registry-Endovascular Treatment trial. Baseline characteristics, procedural parameters, and functional outcome at 90 days were compared between young (<50 years) and older (⩾50 years) patients with and without nearest-neighbor 1:1 propensity score matching.

RESULTS

Out of 6628 acute ischemic stroke patients treated with ET, 363 (5.5%) were young. Young patients differed with regard to prognostic outcome characteristics. Specifically, National Institutes of Health Stroke Scale (NIHSS) at admission was lower (median 13, interquartile range (IQR) 8-17 vs. 15, IQR 9-19, p < 0.001), and prestroke dependence was less frequent (2.9% vs. 12.2%, p < 0.001) than in older patients. Compared to a matched cohort of older patients, ET was faster (time from groin puncture to flow restoration, 35 vs. 45 min, p < 0.001) and intracranial hemorrhage was less frequent in young patients (10.0% vs. 25.9%, p < 0.001). Good functional outcome (modified Rankin Scale (mRS) 0-2) at 3 months was achieved more frequently in young patients (71.6% vs. 44.1%, p < 0.001), and overall mortality was lower (6.7% vs. 25.4%, p < 0.001). Among previously employed young patients (n = 177), 37.9% returned to work at 3-month follow-up, while 74.1% of the remaining patients were still undergoing rehabilitation.

CONCLUSION

Young stroke patients undergoing ET have better outcomes compared to older patients, even when matched for prestroke condition, comorbidities, and stroke severity. Hence, more liberal guidelines to perform ET for younger patients may have to be established by future studies.

Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: External Validation of Prediction Models

BACKGROUND

Symptomatic intracranial hemorrhage (sICH) is a severe complication of reperfusion therapy for ischemic stroke. Multiple models have been developed to predict sICH or intracranial hemorrhage (ICH) after reperfusion therapy. We provide an overview of published models and validate their ability to predict sICH in patients treated with endovascular treatment in daily clinical practice.

METHODS

We conducted a systematic search to identify models either developed or validated to predict sICH or ICH after reperfusion therapy (intravenous thrombolysis and/or endovascular treatment) for ischemic stroke. Models were externally validated in the MR CLEAN Registry (n=3180; Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands). The primary outcome was sICH according to the Heidelberg Bleeding Classification. Model performance was evaluated with discrimination (c-statistic, ideally 1; a c-statistic below 0.7 is considered poor in discrimination) and calibration (slope, ideally 1, and intercept, ideally 0).

RESULTS

We included 39 studies describing 40 models. The most frequently used predictors were baseline National Institutes of Health Stroke Scale (NIHSS; n=35), age (n=22), and glucose level (n=22). In the MR CLEAN Registry, sICH occurred in 188/3180 (5.9%) patients. Discrimination ranged from 0.51 (SPAN-100 [Stroke Prognostication Using Age and National Institutes of Health Stroke Scale]) to 0.61 (SITS-SICH [Safe Implementation of Treatments in Stroke Symptomatic Intracerebral Hemorrhage] and STARTING-SICH [STARTING Symptomatic Intracerebral Hemorrhage]). Best calibrated models were IST-3 (intercept, -0.15 [95% CI, -0.01 to -0.31]; slope, 0.80 [95% CI, 0.50-1.09]), SITS-SICH (intercept, 0.15 [95% CI, -0.01 to 0.30]; slope, 0.62 [95% CI, 0.38-0.87]), and STARTING-SICH (intercept, -0.03 [95% CI, -0.19 to 0.12]; slope, 0.56 [95% CI, 0.35-0.76]).

CONCLUSIONS

The investigated models to predict sICH or ICH discriminate poorly between patients with a low and high risk of sICH after endovascular treatment in daily clinical practice and are, therefore, not clinically useful for this patient population.

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

INTRODUCTION

This meta-analysis assessed the predictors of symptomatic intracranial hemorrhage (sICH) after endovascular thrombectomy (EVT) for patients with acute ischemic stroke.

METHODS

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.

RESULTS

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; p < 0.00001), higher initial NIHSS score (MD = 1.71, 95% CI: 1.35-2.08, p < 0.00001), higher initial systolic blood pressure (MD = 7.40, 95% CI: 5.11-9.69, p < 0.00001), diabetes mellitus (OR = 1.36, 95% CI: 1.10-1.69, p = 0.005), poor collaterals (OR = 3.26, 95% CI: 2.35-4.51; p < 0.0001), internal carotid artery occlusion (OR = 1.55, 95% CI: 1.26-1.90; p < 0.0001), longer procedure time (MD = 18.92, 95% CI: 11.49-26.35; p < 0.0001), and passes of retriever >3 (OR = 3.39, 95% CI: 2.45-4.71; p < 0.0001) were predictors of sICH, while modified thrombolysis in cerebral infarction score ≥2b (OR = 0.61, 95% CI: 0.46-0.79; p = 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.

CONCLUSIONS

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.

ANAID-ICH nomogram for predicting unfavorable outcome after intracerebral hemorrhage

OBJECTIVE

Diffusion-weighted imaging lesions (DWILs) are associated with unfavorable outcome in intracerebral hemorrhage (ICH). We proposed a novel predictive nomogram incorporating DWILs.

METHODS

A total of 738 patients with primary ICH in a tertiary hospital were prospectively enrolled as a training cohort. DWILs were defined as remote focal hyperintensities on DWI corresponding to low intensities on apparent diffusion coefficient images and remote from the focal hematoma. The outcome of interest was modified Rankin Scale scores of 4-6 at 90 days after onset. Multivariate logistic regression was used to construct a nomogram. Model performance was tested in the training cohort and externally validated with respect to discrimination, calibration, and clinical usefulness in another institute. Additionally, the nomogram was compared with the ICH score in terms of predictive ability.

RESULTS

Overall, 153 (20.73%) and 23 (15.54%) patients developed an unfavorable outcome in the training and validation cohorts, respectively. The multivariate analysis revealed that age, National Institutes of Health Stroke Scale (NIHSS) score, anemia, infratentorial location, presence of DWILs, and prior ICH were associated with unfavorable outcome. Our ANAID-ICH nomogram was constructed according to the aforementioned variables; the area under the receiver operating characteristic curve was 0.842 and 0.831 in the training and validation sets, respectively. With regard to the 90-day outcome, the nomogram showed a significantly higher predictive value than the ICH score in both cohorts.

CONCLUSIONS

The ANAID-ICH nomogram comprising age, NIHSS score, anemia, infratentorial location, presence of DWILs, and prior ICH may facilitate the identification of patients at higher risk for an unfavorable outcome.

Safety and efficacy of periprocedural antithrombotics in patients with successful reperfusion after endovascular stroke treatment

OBJECTIVES

We aimed to evaluate whether the overall harmful effect of periprocedural treatment with aspirin or heparin during endovascular stroke treatment is different in patients with a successful reperfusion after the procedure.

MATERIALS AND METHODS

We performed a post-hoc analysis of the MR CLEAN-MED trial, including adult patients with a large vessel occlusion in the anterior circulation eligible for endovascular treatment (EVT). In this trial, patients were randomized for periprocedural intravenous treatment with aspirin or no aspirin (1:1 ratio), and for moderate-dose unfractionated heparin, low-dose unfractionated heparin or no unfractionated heparin (1:1:1 ratio). We tested for interaction between the post-EVT extended thrombolysis in cerebral infarction (eTICI) score and treatment with periprocedural medication with multivariable regression analyses. The primary outcome was the modified Rankin Scale score at 90 days. Secondary outcomes were final infarct volume, intracranial hemorrhage, and symptomatic intracranial hemorrhage.

RESULTS

Of 534 included patients, 93 (17%) had a post-EVT eTICI score of 0-2a, 115 (22%) a score of 2b, 73 (14%) a score of 2c, and 253 (47%) a score of 3. For both aspirin and heparin, we found no interaction between post-EVT eTICI score and treatment on the modified Rankin Scale score (p=0.76 and p=0.47, respectively). We found an interaction between post-EVT eTICI score and treatment with heparin on the final infarct volume (p=0.01). Of note, this interaction showed a biologically implausible distribution over the subgroups.

CONCLUSIONS

The overall harmful effect of periprocedural aspirin and unfractionated heparin is not different in patients with a successful reperfusion after EVT.

Value of Angiographic Regional Circulation Signs in Predicting Hemorrhagic Transformation after Endovascular Thrombectomy

OBJECTIVE

The aim of this study was to evaluate the predictive value of the early venous filling (EVF) sign, the basal ganglia blush (BGB) sign and both the EVF and BGB signs for the hemorrhagic transformation (HT) and parenchymal hematoma (PH) in patients after endovascular thrombectomy.

METHODS

This study included patients with anterior circulation large vessel occlusive stroke treated with endovascular thrombectomy from May 2017 to December 2021. The predictive value of regional circulation signs for HT and PH were assessed using logistic regression models adjusted for confounders, and further a multiplicative interaction term was added to investigate the effect of different stroke severity on its predictive value.

RESULTS

Among the 350 patients included and after adjusting for confounders, those with the EVF sign (adjusted OR=3.934, 95% CI:2.326-6.655), the BGB sign (adjusted OR=3.776, 95% CI:2.341-6.089), and both the EVF and BGB signs (adjusted OR=3.250, 95% CI: 1.886-5.600) were more likely to have HT. The EVF sign (adjusted OR=3.545, 95% CI:2.036-6.170), the BGB sign (adjusted OR=3.742, 95% CI:2.110-6.639), and both the EVF and BGB signs (adjusted OR=3.139, 95% CI: 1.776-5.549) were also significantly correlated with PH. When stratified according to stroke severity, we further found there were significant interactions between regional circulation signs and stroke severity on postoperative HT and PH (all P for interaction < 0.001).

CONCLUSIONS

Regional circulation signs were independently associated with HT and PH after endovascular thrombectomy and had a higher predictive value in patients with severe stroke compared with mild to moderate stroke.

TAGE Score for Symptomatic Intracranial Hemorrhage Prediction After Successful Endovascular Treatment in Acute Ischemic Stroke

BACKGROUND

Determine if early venous filling (EVF) after complete successful recanalization with mechanical thrombectomy in acute ischemic stroke is an independent predictor of symptomatic intracranial hemorrhage (sICH) and integrate EVF into a risk score for sICH prediction.

METHODS

Consecutive patients with anterior acute ischemic stroke treated by mechanical thrombectomy issued from patients enrolled in the THRACE trial (Thrombectomie des Artères Cérébrales) and from 2 prospective registries were included and divided into a derivation (Center I; n=402) and validation cohorts (THRACE and center 2; n=507). EVF was evaluated by 2 blinded readers. sICH was defined according to the modified European cooperative acute stroke study II. Clinical and radiological data were analyzed in the derivation cohort (C1) to identify independent predictors of sICH and construct a predictive score test on the validation cohort (THRACE + C2).

RESULTS

Symptomatic ICH rate was similar between the two cohorts (9.9% and 8.9% respectively, P=0.9). Time from onset-to-successful recanalization >270 minutes (odds ratio [OR], 7.8 [95% CI, 2.5-24]), Alberta Stroke Program Early CT Score (≤5 [OR, 2.49 (95% CI, 1.8-8.1) or 6-7 [OR, 1.15 (95% CI, 1.03-4.46)]), glucose blood level >7 mmol/L (OR, 2.92 [95% CI, 1.26-6.7]), and EVF presence (OR, 11.9 [95% CI, 3.8-37.5]) were independent predictors of sICH and constituted the Time-Alberta Stroke Program Early CT-Glycemia-EVF score. Time-Alberta Stroke Program Early CT-Glycemia-EVF score was associated with an increased risk of sICH in the derivation cohort (OR increase per unit, 1.99 [95% CI, 1.53-2.59]; P<0.001) with area under the curve, 0.832 [95% CI, 0.767-0.898]. The score had good performance in the validation cohort (area under the curve, 0.801 [95% CI, 0.69-0.91]).

CONCLUSIONS

Time-Alberta Stroke Program Early CT-Glycemia-EVF score is a simple tool with readily available clinical variables with good performances for sICH prediction after mechanical thrombectomy.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT01062698.

Determinants of Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: A Retrospective Cohort Study

Symptomatic intracranial hemorrhage (sICH) is a serious complication after endovascular treatment for ischemic stroke. We aimed to identify determinants of its occurrence and location.

A Nomogram for Individualized Prediction of Stress-Related Gastrointestinal Bleeding in Critically Ill Patients with Primary Intracerebral Hemorrhage

PURPOSE

To establish and validate a nomogram model for predicting stress-related gastrointestinal bleeding in critically ill patients with primary intracerebral hemorrhage.

PATIENTS AND METHODS

From January 2018 to March 2021, we conducted a hospital-based study by screening eligible patients with acute intracerebral hemorrhage. Univariate and multivariate logistic regression analyses were performed to determine the predictors for stress-related gastrointestinal bleeding in patients with primary intracerebral hemorrhage. The nomogram was constructed on the basis of multivariate logistic model and was internally validated by bootstrap resampling. The discriminative performance of the nomogram was evaluated using the calibration and concordance index (C-index), which was equal to the area under the curve of receiver-operating characteristics. Hosmer-Lemeshow test was performed to check the model's goodness of fit. A decision curve analysis was used to assess its clinical utility.

RESULTS

A total of 410 patients were enrolled in this study. Stress-related gastrointestinal bleeding occurred in 115 patients (28.0%). Multivariate analysis demonstrated that gastric pH at admission [odds ratio (OR): 0.52, 95% confidence interval (CI): 0.41-0.66, P < 0.001], ICH volume (OR: 1.03, 95% CI: 1.02-1.05, P < 0.001) and sepsis (OR: 2.56, 95% CI: 1.54-4.25, P < 0.001) were independent predictors for stress-related gastrointestinal bleeding in critically ill patients with ICH. The nomogram including gastric pH at admission, ICH volume and sepsis presented good discrimination with C-index of 0.770 (95% CI: 0.716 to 0.822), which was confirmed to be 0.764 through bootstrapping validation. The calibration plot showed good agreement between the predicted and observed outcomes. The Hosmer-Lemeshow test showed a goodness-of-fit (Chi-Square = 8.085, DF = 8, P = 0.425). Decision curve analysis demonstrated that the nomogram was clinically beneficial.

CONCLUSION

The proposed nomogram based on gastric pH at admission, ICH volume and sepsis can accurately predict the risk of stress-related gastrointestinal bleeding in critically ill patients with primary intracerebral hemorrhage.

Nomogram to Predict the Number of Thrombectomy Device Passes for Acute Ischemic Stroke with Endovascular Thrombectomy

Purpose

This study aimed to determine the risk factors associated with the number of thrombectomy device passes and establish a nomogram for predicting the number of device pass attempts in patients with successful endovascular thrombectomy (EVT).

Methods

We enrolled patients from a signal comprehensive stroke center (CSC) who underwent EVT because of large vessel occlusion stroke. Multivariate logistic regression analysis was used to develop the best-fit nomogram for predicting the number of thrombectomy device passes. The discrimination and calibration of the nomogram were estimated using the area under the receiver operating characteristic curve (AUC-ROC) and a calibration plot with a bootstrap of 1000 resamples. A decision curve analysis (DCA) was used to measure the availability and effect of this predictive tool.

Results

In total, 130 patients (mean age 64.9 ± 11.1 years; 83 males) were included in the final analysis. Age (odds ratio [OR], 1.085; 95% confidence interval [CI], 1.005-1.172; p = 0.036), baseline Alberta Stroke Program Early computed tomography (ASPECTS) score (OR, 0.237; 95% CI, 0.115-0.486; p < 0.001), and homocysteine level (OR, 1.090; 95% CI, 1.028-1.155; p = 0.004) were independent predictors of device pass number and were thus incorporated into the nomogram. The AUC-ROC determined the discrimination ability of the nomogram, which was 0.921 (95% CI, 0.860-0.980), which indicated good predictive power. Moreover, the calibration plot revealed good predictive accuracy of the nomogram. The DCA demonstrated that when the threshold probabilities of the cohort ranged between 5.0% and 98.0%, the use of the nomogram to predict a device pass number > 3 provided greater net benefit than did "treat all" or "treat none" strategies.

Conclusion

The nomogram comprised age, baseline ASPECTS score, and homocysteine level, can predict a device pass number >3 in acute ischemic stroke (AIS) patients who are undergoing EVT.

Construction of a nomogram to reveal the prognostic benefit of spontaneous intracranial hemorrhage among Chinese adults: a population-based study

BACKGROUND AND PURPOSE

We aimed to build a nomogram, based on patients with spontaneous intracerebral hemorrhage (SICH), to predict the probability of mortality and morbidity at 7 days and 90 days, respectively.

METHODS

We performed a retrospective study, with patients at less than 6 h from ictus admitted to the department of neurosurgery in a single institute, from January 2011 to December 2018. A total of 1036 patients with SICH were included, 486 patients (46.9%) were 47-66 years old at diagnosis, and 711 patients (68.6%) were male. The least absolute shrinkage and section operator method was performed to identify the key adverse factors predicting the outcomes in patients with SICH, and multivariate logistic regression analysis was built on these variables, and then the results were visualized by a nomogram. The discrimination of the prognostic models was measured and compared by means of Harrell's concordance index (C-index), calibration curve, area under the curve (AUC), and decision curve analysis (DCA).

RESULTS

Multivariate logistic regression analysis revealed that factors affecting 7-day mortality, including the following: age, therapy, Glasgow Coma Scale (GCS) admission, location, ventricle involved, hematoma volume, white blood cell (WBC), uric acid (UA), and L-lactic dehydrogenase (LDH); and factors affecting 90-day mortality, including temperature, therapy, GCS admission, ventricle involved, WBC, international normalized ratio, UA, LDH, and systolic blood pressure. The C-index for the 7-day mortality and 90-day mortality prediction nomogram was 0.9239 (95% CI = 0.9061-0.9416) and 0.9241 (95% CI = 0.9064-0.9418), respectively. The AUC of 7-day mortality was 92.4, as is true of 90-day mortality. The calibration curve and DCA indicated that nomograms in our study had a good prediction ability. For 90-day morbidity, age, marital status, and GCS at 7-day remained statistically significant in multivariate analysis. The C-index for the prediction nomogram was 0.6898 (95% CI = 0.6511-0.7285), and the calibration curve, AUC as well as DCA curve indicated that the nomogram for the prediction of good outcome demonstrated good agreement in this cohort.

CONCLUSIONS

Nomograms in this study revealed many novel prognostic demographic and laboratory factors, and the individualized quantitative risk estimation by this model would be more practical for treatment management and patient counseling.

A Prospective Study to Investigate Controlling Blood Pressure Under Transcranial Doppler After Endovascular Treatment in Patients With Occlusion of Anterior Circulation

Objective: The objective of this study was to evaluate the effect of blood pressure (BP) management with transcranial Doppler (TCD) guidance in patients with large-vessel occlusion in the anterior circulation after endovascular thrombectomy (EVT) on the long-term prognosis.

Methods: This was a prospective study; 232 patients were nonrandomized assigned to TCD-guided BP management (TBM) group or non-TCD-guided BP management (NBM) group. In the TBM group, BP was controlled according to TCD showing cerebral blood flow fluctuation. In the NBM group, BP was controlled according to the guidelines. The primary endpoint was a modified Rankin scale (mRS) score of 2 or lower at 90 days. The safety outcomes were the rates of symptomatic or any intracerebral hemorrhage (ICH) and mortality at 90 days.

Results: One hundred sixty-three patients were assigned to the TBM group, and 69 were assigned to the NBM group. In the propensity score-matched cohort (65 matches in both groups), there was significant difference in the proportion of participants with mRS 0–2 at 90 days according to BP management (adjusted odds ratio 3.34, 95% CI 1.36 to 8.22). There was no difference in the rates of symptomatic or any ICH and mortality between two groups. In inverse probability-weighted regression adjustment analysis, mortality decreased significantly in the TBM group than in the NBM group (adjusted odds ratio 0.86, 95% CI 0.76–0.99, p = 0.03).

Conclusion: In patients with acute ischemic stroke from large-vessel occlusion in the anterior circulation, BP management under TCD was superior to NBM in improving the clinical outcomes at 90 days.

Clinical Trial Registration: (URL: https://www.chictr.org.cn/showproj.aspx?proj=55484; Identifier: ChiCTR2000034443.

Comparison of risk scores in predicting symptomatic intracerebral hemorrhage after endovascular thrombectomy

BACKGROUND/PURPOSE

Several risk scores have been developed to predict symptomatic intracerebral hemorrhage (SICH) after acute reperfusion therapy for ischemic stroke. We compared the performance of established risk scores in predicting SICH after EVT under different SICH criteria.

METHODS

A total of 258 patients with anterior circulation large vessel occlusion who received EVT in two medical centers of Taiwan were recruited. Three definitions of SICH, the European Collaborative Acute Stroke Study II (ECASS II), ECASS III, and the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST), were used. The HAT, SITS-SICH, SEDAN, and TAG risk scores were applied. Logistic regression and area under the receiver operating characteristic curve (AUC) were used to evaluate the performance of each risk model.

RESULTS

In the 258 included patients (mean age, 71.9 ± 11.8 years; men, 48.1%), the observed rates of SICH according to ECASS II, ECASS III, and SITS-MOST criteria were 10.1%, 5.0%, and 4.7%, respectively. Higher glucose level (>160 mg/dL) and unsuccessful recanalization independently predicted SICH under all criteria. Among the different risk scores, only SEDAN and TAG consistently predicted SICH. SEDAN and TAG scores exhibited the highest AUC in predicting SICH for ECASS III (SEDAN 0.72, TAG 0.72) and SITS-MOST (SEDAN 0.73, TAG 0.70) criteria.

CONCLUSION

Among various risk scores, the TAG and SEDAN scores best predict SICH after EVT. Higher glucose level and unsuccessful recanalization, which are included in the TAG and SEDAN scores, are independent risk factors of SICH in the present cohort, highlighting their detrimental effects.

Nomogram for the Prediction of Intrahospital Mortality Risk of Patients with ST-Segment Elevation Myocardial Infarction Complicated with Hyperuricemia: A Multicenter Retrospective Study

Purpose

This study aimed to establish an accurate and easy predictive model for ST-segment elevation myocardial infarction (STEMI) patients with hyperuricemia, using readily available features to estimate intrahospital mortality risk.

Patients and Methods

This was a multicenter retrospective study involving the development of risk prediction models for intrahospital mortality among all STEMI patients with hyperuricemia from Zunyi Medical University Chest Pain Center’s specialized alliance between January 1, 2016 and June 30, 2020. The primary outcome was intrahospital mortality. A total of 48 candidate variables were considered from demographic and clinical data. The least absolute shrinkage and selection operator (LASSO) was used to develop a nomogram. Concordance index values, decision curve analysis, the area under the curve (AUC), and clinical impact curves were examined. In this study, 489 patients with STEMI were included in the training dataset and an additional 209 patients from the 44 chest pain centers were included in the test cohort. B-type natriuretic peptides, α-hydroxybutyrate dehydrogenase (α-HBDH), cystatin C, out-of-hospital cardiac arrest (OHCA), shock index, and neutrophil-to-lymphocyte ratio were associated with intrahospital mortality and included in the nomogram.

Results

The model showed good discrimination power, and the AUC generated to predict survival in the training set was 0.875 (95% confidence interval, 0.825–0.925). In the validation set, the AUC of survival predictions was 0.87 (95% confidence interval, 0.792–0.947). Calibration plots and decision curve analysis showed good model performance in both datasets. A web-based calculator (https://bzxzmu.shinyapps.io/STEMI-with-Hyperuricemia-intrahospital-mortality/) was established based on the nomogram model, which was used to measure the levels of OHCA, neutrophil-to-lymphocyte ratio, shock index, α-HBDH, cystatin C, and B-type natriuretic peptides.

Conclusion

For practical applications, this model may prove clinically useful for personalized therapy management in patients with STEMI with hyperuricemia.

Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.

Developing a Nomogram to Predict the Probability of Subsequent Vascular Events at 6-Month in Chinese Patients with Minor Ischemic Stroke

Purpose

To develop a nomogram to predict the risk of subsequent vascular events (SVE) at 6-month in Chinese patients with minor ischemic stroke (MIS).

Patients and Methods

We performed a retrospective analysis of 260 MIS patients, which were randomly divided into a derivation set (193 cases) and a verification set (67 cases) at a ratio of 3:1. Multi-factor logistic regression was used to construct a predictive model of SVE from the derivation set and verify it in the verification set.

Results

Finally, there were 51 cases (19.6%) of SVE in 260 MIS cases. Age, fasting blood glucose, metabolic syndrome, number of lesions found on MRI, and the infarct size were used to construct the prediction model and nomogram. The AUC in the derivation set was 0.901, with a sensitivity of 0.795, a specificity of 0.877, a positive likelihood ratio of 6.443, and a negative likelihood ratio of 0.234. The AUC in the verification set was 0.897, which was not significantly different from the derivation set (P = 0.937). The predictive model based on clinical parameters has good diagnostic efficiency and robustness.

Conclusion

The nomogram can provide personalized predictions for the 6-month SVE risk in Chinese MIS patients.

Nomogram to Predict Cognitive Dysfunction After a Minor Ischemic Stroke in Hospitalized-Population

An easily scoring system to predict the risk of cognitive impairment after minor ischemic stroke has not been available. We aimed to develop and externally validate a nomogram for predicting the probability of post-stroke cognitive impairment (PSCI) among hospitalized population with minor stroke. Moreover, the association of Trimethylamine N-oxide (TMAO) with PSCI is also investigated. We prospectively conducted a developed cohort on collected data in stroke center from June 2017 to February 2018, as well as an external validation cohort between June 2018 and February 2019. The main outcome is cognitive impairment defined as <22 Montreal Cognition Assessment (MoCA) score points 6 – 12 months following a minor stroke onset. Based on multivariate logistic models, the nomogram model was generated. Plasma TMAO levels were assessed at admission using liquid chromatography tandem mass spectrometry. A total of 228 participants completed the follow-up data for generating the nomogram. After multivariate logistic regression, seven variables remained independent predictors of PSCI to compose the nomogram included age, female, Fazekas score, educational level, number of intracranial atherosclerotic stenosis (ICAS), HbA1c, and cortical infarction. The area under the receiver-operating characteristic (AUC-ROC) curve of model was 0.829, C index was good (0.810), and the AUC-ROC of the model applied in validation cohort was 0.812. Plasma TMAO levels were higher in patients with cognitive impairment than in them without cognitive dysfunction (median 4.56 vs. 3.22 μmol/L; p ≤ 0.001). In conclusion, this scoring system is the first nomogram developed and validated in a stroke center cohort for individualized prediction of cognitive impairment after minor stroke. Higher plasma TMAO level at admission suggests a potential marker of PSCI.

Number of Retrieval Attempts Rather Than Procedure Time Is Associated With Risk of Symptomatic Intracranial Hemorrhage

Supplemental Digital Content is available in the text.

Background and Purpose:

Endovascular therapy is the standard of care in the treatment of acute ischemic stroke due to large-vessel occlusion. A direct association between the number of device passes and the occurrence of symptomatic intracranial hemorrhage (SICH) has been suggested. This study represents an in-depth investigation of the hypothesis that >3 retrieval attempts is associated with an increased rate of SICH in a large multicenter patient cohort.

Methods:

Two thousand six hundred eleven patients from the prospective German Stroke Registry were analyzed. Patients who received Endovascular therapy for acute large-vessel occlusion of the anterior circulation with known admission National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score, final Thrombolysis in Cerebral Infarction, and number of retrieval passes were included. The primary outcome was defined as SICH. The secondary outcome was any type of radiologically confirmed intracranial hemorrhage within the first 24 hours. Multivariate mixed-effects models were used to adjust for cluster effects of the participating centers, as well as for confounders.

Results:

Five hundred ninety-three patients fulfilled the inclusion criteria. The median number of retrieval passes was 2 [interquartile range, 1–3]. SICH occurred in 26 cases (4.4%), whereas intracranial hemorrhage was identified by neuroimaging in 85 (14.3%) cases. More than 3 retrieval passes was the strongest predictor for SICH (odds ratio, 3.61 [95% CI, 1.38–9.42], P=0.0089) following adjustment for age, admission National Institutes of Health Stroke Scale, admission Alberta Stroke Program Early CT Score, and Thrombolysis in Cerebral Infarction, as well as time from symptom onset to flow restoration. Baseline Alberta Stroke Program Early CT Score of 8 to 9 (odds ratio, 0.26 [95% CI, 0.07–0.89], P=0.032) or 10 (odds ratio, 0.21 [95% CI, 0.06–0.78], P=0.020) were significant protective factors against the occurrence of SICH.

Conclusions:

More than 3 retrieval attempts is associated with a significant increase in SICH risk, regardless of patient age, baseline National Institutes of Health Stroke Scale, or procedure time. This should be considered when deciding whether to continue a procedure, especially in patients with large baseline infarctions.

Registration:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03356392.

Intracranial Bleeding After Reperfusion Therapy in Acute Ischemic Stroke

Intracranial hemorrhage is one of the most feared complications following brain infarct. Ischemic tissues have a natural tendency to bleed. Moreover, the first recanalization trials using intravenous thrombolysis have shown an increase in mild to severe intracranial hemorrhage. Symptomatic intracerebral hemorrhage is strongly associated with poor outcomes and is an important factor in recanalization decisions. Stroke physicians have to weigh the potential benefit of recanalization therapies, first, with different risks of intracranial hemorrhage described in randomized controlled trials, and second with numerous risk markers that have been found to be associated with intracranial hemorrhage in retrospective series. These decisions have become quite complex with different intravenous thrombolytics and mechanical thrombectomy. This review aims to outline some elements of the pathophysiological mechanisms and classifications, describe most of the risk factors identified for each reperfusion therapy, and finally suggest future research directions that could help physicians dealing with these complications.

Safety and Angiographic Efficacy of Intra-Arterial Fibrinolytics as Adjunct to Mechanical Thrombectomy: Results from the INFINITY Registry

Background and Purpose

Data on safety and efficacy of intra-arterial (IA) fibrinolytics as adjunct to mechanical thrombectomy (MT) are sparse.

Methods

INtra-arterial FIbriNolytics In ThrombectomY (INFINITY) is a retrospective multi-center observational registry of consecutive patients with anterior circulation large-vessel occlusion ischemic stroke treated with MT and adjunctive administration of IA fibrinolytics (alteplase [tissue plasminogen activator, tPA] or urokinase [UK]) at 10 European centers. Primary outcome was the occurrence of symptomatic intracranial hemorrhage (sICH) according to the European Cooperative Acute Stroke Study II definition. Secondary outcomes were mortality and modified Rankin Scale (mRS) scores at 3 months.

Results

Of 5,612 patients screened, 311 (median age, 74 years; 44.1% female) received additional IA after or during MT (194 MT+IA tPA, 117 MT+IA UK). IA fibrinolytics were mostly administered for rescue of thrombolysis in cerebral infarction (TICI) 0-2b after MT (80.4%, 250/311). sICH occurred in 27 of 308 patients (8.8%), with an increased risk in patients with initial TICI0/1 (adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1 to 5.0 per TICI grade decrease) or in those with intracranial internal carotid artery occlusions (aOR, 3.7; 95% CI, 1.2 to 12.5). In patients with attempted rescue of TICI0-2b and available angiographic follow-up, 116 of 228 patients (50.9%) showed any angiographic reperfusion improvement after IA fibrinolytics, which was associated with mRS ≤2 (aOR, 3.1; 95% CI, 1.4 to 6.9).

Conclusions

Administration of IA fibrinolytics as adjunct to MT is performed rarely, but can improve reperfusion, which is associated with better outcomes. Despite a selection bias, an increased risk of sICH seems possible, which underlines the importance of careful patient selection.

Bridging May Increase the Risk of Symptomatic Intracranial Hemorrhage in Thrombectomy Patients With Low Alberta Stroke Program Early Computed Tomography Score

BACKGROUND AND PURPOSE

Whether intravenous thrombolysis (IVT) increases the risk for symptomatic intracranial hemorrhage (sICH) in patients treated with mechanical thrombectomy (MT) is a matter of debate. Purpose of this study was to evaluate the extent of early ischemia as a possible factor influencing the risk for sICH after IVT+MT versus direct MT.

METHODS

An explorative analysis of the BEYOND-SWIFT (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy) multicenter cohort was performed. We hypothesized that the sICH risk between IVT+MT versus direct MT differs across the strata of Alberta Stroke Program Early CT Scores (ASPECTS). For this purpose, all patients with ICA, M1, and M2 vessel occlusions and available noncontrast computed tomography or diffusion-weighed imaging ASPECTS (n=2002) were analyzed. We used logistic regression analysis in subgroups, as well as interaction terms, to address the risk of sICH in IVT+MT versus direct MT patients across the ASPECTS strata.

RESULTS

In 2002 patients (median age, 73.7 years; 50.7% women; median National Institutes of Health Stroke Scale score, 16), the overall rate of sICH was 6.5% (95% CI, 5.5%-7.7%). Risk of sICH differed across ASPECTS groups (9-10: 6.3%; 6-8: 5.6% and ≤5 9.8%; P=0.042). With decreasing ASPECTS, the risks of sICH in the IVT+MT versus the direct MT group increased from adjusted odds ratio of 0.61 ([95% CI, 0.24-1.60] ASPECTS 9-10), to 1.72 ([95% CI, 0.69-4.24] ASPECTS 6-8) and 6.31 ([95% CI, 1.87-21.29] ASPECTS ≤5), yielding a positive interaction term (1.91 [95% CI, 1.01-3.63]). Sensitivity analyses regarding diffusion-weighed imaging versus noncontrast computed tomography ASPECTS did not alter the primary observations.

CONCLUSIONS

The extent of early ischemia may influence relative risks of sICH in IVT+MT versus direct MT patients, with an excess sICH risk in IVT+MT patients with low ASPECTS. If confirmed in post hoc analyses of randomized controlled trial data, IVT may be administered more carefully in patients with low ASPECTS eligible for and with direct access to MT.

Endovascular treatment of acute ischemic stroke due to tandem lesions of the anterior cerebral circulation: a multicentric Italian observational study

PURPOSE

Acute ischemic stroke (AIS) due to tandem lesions (TLs) of extracranial Internal Carotid Artery and Anterior Cerebral Circulation are challenging for endovascular treatment (EVT). This study aims to evaluate feasibility, safety and efficacy of EVT for TLs' AIS, with or without emergent carotid artery stenting (eCAS), in a real-life scenario.

METHODS

Retrospective review of prospectively collected non-randomized thrombectomy databases from five stroke centers between 2015 and 2019. Consecutive patients with TLs' AIS were selected. Clinical, neuroimage and procedure features, as well as antiplatelet therapy regimen, were evaluated. Primary outcome was 90-day mRS ≤ 2. Secondary outcomes included: mTICI score 2b-3, extracranial recanalization, procedural complications, symptomatic intracerebral hemorrhage (SICH) and 90-day mortality.

RESULTS

Two hundred twenty-seven patients were enrolled (67.8% males; mean age 65.9 ± 12.9 years). We obtained mTICI 2b-3 in 77.1%, extracranial recanalization in 86.8%, 90-day mRS (available in 201/227 cases) ≤ 2 in 49.8%. Procedural complications occurred in 16.7%, SICH in 9.7%; 90-day mortality rate (available in 201/227 cases) was 14.4%. The strongest predictors of good clinical outcome were young age (p < 0.0001), low baseline NIHSS (p = 0.008), high baseline ASPECTS (p < 0.0001), good collateral flow (p = 0.013) and extracranial recanalization (p = 0.001). The most significant predictors of SICH were low baseline ASPECTS (p < 0.0001), occurrence of complications (p < 0.0001) and eCAS (p = 0.002).

CONCLUSION

In our real-life series, the EVT for TLs' AIS was feasible, safe and effective in improving 90-day functional outcome with acceptable morbi-mortality rates. ECAS increased the risk of SICH, independently from the antiplatelet therapy regimen.

The feasibility of dual-energy CT to predict the probability of symptomatic intracerebral haemorrhage after successful mechanical thrombectomy

AIM

To study the ability of dual-energy computed tomography (DECT) after successful mechanical thrombectomy (MT) to predict symptomatic intracerebral haemorrhage (sICH) in anterior circulation acute ischaemic stroke (AIS).

MATERIALS AND METHODS

From June 2018 to February 2020, 102 AIS patients with DECT performed immediately after successful MT were enrolled prospectively. According to the presence of iodine contrast media extravasation (ICME) on DECT and subsequent sICH development, patients were classified into four groups. The neurological outcome was compared among groups. Imaging parameters, together with clinical factors, were investigated for sICH prediction based on a linear logistic regression model after class-imbalance resolved by Synthetic Minority Sampling Technique (SMOTE) method.

RESULTS

Among 102 patients, patients (14.7%, 15/102) with the presence of sICH experienced worse outcomes than others without sICH (p<0.001). No case without ICME was observed with sICH development (0/102). The parameters derived from DECT have excellent performance for sICH prediction after successful MT, which is better than clinical predictive model boosted data (area under the curve [AUC]: DECT 0.87 versus clinical prediction 0.65), cross-validation results (AUC: DECT 0.87 versus clinical prediction 0.65), and original data (AUC: DECT 0.85 versus clinical prediction 0.68). By combining clinical and radiological parameters, the predictive performance for sICH could be further improved with an AUC of 0.90 (95% CI: 0.85-0.96).

CONCLUSIONS

Based on DECT parameters acquired immediately after successful MT, the present model was more efficient than the clinical model for accurate prediction of sICH. Rho and ICME volume appeared to be the best parameters for predicting sICH using DECT.

Microbleeds, Cerebral Hemorrhage, and Functional Outcome After Endovascular Thrombectomy

OBJECTIVE

To determine whether pretreatment cerebral microbleeds (CMBs) presence and burden are correlated with an increased risk of intracranial hemorrhage (ICH) or poor functional outcome following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS).

METHODS

Consecutive patients treated by EVT for anterior circulation AIS were retrospectively analyzed. Experienced neuroradiologists blinded to functional outcomes rated CMBs on T2*-MRI using a validated scale. We investigated associations of CMB presence and burden with ICH and poor clinical outcome at 3 months (modified Rankin Scale score >2).

RESULTS

Among 513 patients, 281 (54.8%) had a poor outcome and 89 (17.3%) had ≥1 CMBs. A total of 190 (37%) patients experienced ICH; 66 (12.9%) were symptomatic. CMB burden was associated with poor outcome in a univariable analysis (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.03-1.36 per 1-CMB increase; p = 0.02), but significance was lost after adjustment for sex, age, stroke severity, hypertension, diabetes mellitus, atrial fibrillation, prior antithrombotic medication, IV thrombolysis, and reperfusion status (OR, 1.05; 95% CI, 0.92-1.20 per 1-CMB increase; p = 0.50). Results remained nonsignificant when taking into account CMB location or presumed underlying pathogenesis. CMB presence, burden, location, or presumed pathogenesis were not independently correlated with ICH.

CONCLUSIONS

Poor functional outcome or ICH were not correlated with CMB presence or burden on pre-EVT MRI after adjustment for confounding factors. Excluding such patients from reperfusion therapies is unwarranted.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that in patients with AIS undergoing EVT, after adjustment for confounding factors, the presence of CMBs is not significantly associated with clinical outcome or the risk of ICH.

Pre-procedural predictive factors of symptomatic intracranial hemorrhage after thrombectomy in stroke

OBJECTIVE

Symptomatic intracerebral hemorrhage (sICH) is a common complication of acute ischemic stroke (AIS) associated with limited treatments and poor outcomes. We aimed to identify predictive factors of sICH in patients with AIS following mechanical thrombectomy (MT) in a real-world setting.

METHODS

Patients with large vessel occlusion of the anterior circulation treated with MT were consecutively included in a prospective monocentric cohort. Clinical, biological, and radiological parameters were collected to identify pre-procedural predictors for sICH.

RESULTS

637 patients were included in our study. Magnetic resonance imaging was performed on most patients (86.7%). sICH occurred in 55 patients (8.6%). 428 patients (67.2%) were treated with intravenous thrombolysis. After multivariate analysis, prior use of antiplatelet therapies (odd ratio (OR) 1.84, 95% confidence interval (CI) 1.01-3.32), high C-reactive protein (OR per standard deviation (SD) increase 1.28, 95% 1.01-1.63), elevated mean arterial blood pressure (OR per 10 mmHg increase 1.22, 95% CI 1.03-1.44), hyperglycemia (OR per one SD-log increase 1.38, 95% CI 1.02-1.87), and low ASPECTS (OR per 1-point decrease 1.42, 95% CI 1.12-1.80) were found to be independent predictive factors of sICH. The pre-procedural predictors did not change when the absence of successful recanalization was considered as a covariate. Patients with strokes of unknown onset time were not especially vulnerable for sICH.

CONCLUSION

sICH after MT was associated with several pre-procedural risk factors: prior use of antiplatelet therapies, high C-reactive protein and hyperglycemia at baseline, elevated mean arterial blood pressure, and low ASPECTS.

A Nomogram to Predict Symptomatic Intracranial Hemorrhage After Intravenous Thrombolysis in Chinese Patients

BACKGROUND AND AIMS

A reliable predictive score system to identify the risk of symptomatic intracranial hemorrhage (sICH) after intravenous thrombolysis (IVT) in acute ischemic stroke patients is of great essence. We aimed to develop a nomogram for predicting the risk of sICH after IVT in Chinese patients.

METHODS

We recruited acute ischemic stroke patients who were treated with IVT from five advanced stroke centers in China from April 2014 to November 2020. sICH was diagnosed according to the European Cooperative Acute Stroke Study II (ECASS-II) definition. Multivariable logistic regression was performed to construct the best-fit nomogram. The discrimination and calibration of the nomogram were evaluated by the area under the receiver operating characteristic curve (AUC-ROC) and calibration plot.

RESULTS

A total of 1200 patients were enrolled, of whom 66 (5.5%) developed sICH. In the multivariate logistic regression model, atrial fibrillation (odds ratio [OR] 3.25; 95% confidence interval [CI], 1.89-5.60; P < 0.001), baseline glucose level (OR, 1.13; 95% CI, 1.07-1.20; P < 0.001), neutrophil to lymphocyte ratio (OR, 1.05; 95% CI, 1.01-1.09; P = 0.024) and baseline National Institute of Health Stroke Scale (NIHSS) (OR, 1.07; 95% CI, 1.04-1.10; P < 0.001) were independent predictors for sICH and were used to generate the nomogram. The nomogram demonstrated good discrimination as the AUC-ROC value was 0.788 (95% CI, 0.737-0.840). The calibration plot revealed good calibration.

CONCLUSION

The nomogram consisted of atrial fibrillation, baseline glucose level, neutrophil to lymphocyte ratio, and NIHSS score may predict the risk of sICH in Chinese acute ischemic stroke patients treated with IVT.

Nomogram to Predict Poor Outcome after Mechanical Thrombectomy at Older Age and Histological Analysis of Thrombus Composition

An easy scoring system to predict the risk of poor outcome after mechanical thrombectomy among the elderly is currently not available. Therefore, we aimed to develop a nomogram for predicting the probability of negative prognosis in aged patients with acute ischemic stroke undergoing thrombectomy. In addition, we sought to investigate the association between histological thrombus composition and stroke characteristics. To this end, we prospectively studied a developed cohort using data collected from a stroke center from November 2015 to December 2019. The main outcome was functional independence, defined as a modified Rankin Scale score ≤ 2 at 90 days following a mechanical thrombectomy. A nomogram model based on multivariate logistic models was generated. The retrieved thrombi were stained with hematoxylin and eosin and assessed according to histological composition. Our results demonstrated that age ≥ 72 years was independently associated with poor outcome. A total of 304 participants completed the follow-up data to generate the nomogram model. After multivariate logistic regression, five variables remained independent predictors of outcome, including older age, hemorrhagic transformation, thrombolysis in cerebral infarction score, National Institute of Health Stroke score, and neutrophil-to-lymphocyte ratio, and were used to generate the nomogram. The area under the receiver-operating characteristic curve of the model was 0.803. The clots from elderly subjects with large-artery atherosclerosis, anterior circulation, and successful recanalization groups had a higher percentage of fibrin compared to those of younger patients. This is the first nomogram to be developed and validated in a stroke center cohort for individualized prediction of poor outcome in elderly patients after mechanical thrombectomy. Clot composition provides valuable information on the underlying pathogenesis of oxidation in older patients.

A new nomogram for individualized prediction of the probability of hemorrhagic transformation after intravenous thrombolysis for ischemic stroke patients

Background

A reliable scoring tool to detect the risk of intracerebral hemorrhage (ICH) after intravenous thrombolysis for ischemic stroke is warranted. The present study was designed to develop and validate a new nomogram for individualized prediction of the probability of hemorrhagic transformation (HT) in patients treated with intravenous (IV) recombinant tissue plasminogen activator (rt-PA).

Methods

We enrolled patients who suffered from acute ischemic stroke (AIS) with IV rt-PA treatment in our emergency green channel between August 2016 and July 2018. The main outcome was defined as any type of intracerebral hemorrhage according to the European Cooperative Acute Stroke Study II (ECASS II). All patients were randomly divided into two cohorts: the primary cohort and the validation cohort. On the basis of multivariate logistic model, the predictive nomogram was generated. The performance of the nomogram was evaluated by Harrell’s concordance index (C-index) and calibration plot.

Results

A total of 194 patients with complete data were enrolled, of whom 131 comprised the primary cohort and 63 comprised the validation cohort, with HT rate 12.2, 9.5% respectively. The score of chronic disease scale (CDS), the global burden of cerebral small vascular disease (CSVD), National Institutes of Health Stroke Scale (NIHSS) score ≥ 13, and onset-to-treatment time (OTT) ≥ 180 were detected important determinants of ICH and included to construct the nomogram. The nomogram derived from the primary cohort for HT had C- Statistics of 0.9562 and the calibration plot revealed generally fit in predicting the risk of HT. Furthermore, we made a comparison between our new nomogram and several other risk-assessed scales for HT with receiver operating characteristic (ROC) curve analysis, and the results showed the nomogram model gave an area under curve of 0.9562 (95%CI, 0.9221–0.9904, P < 0.01) greater than HAT (Hemorrhage After Thrombolysis), SEDAN (blood Sugar, Early infarct and hyper Dense cerebral artery sign on non-contrast computed tomography, Age, and NIHSS) and SPAN-100 (Stroke Prognostication using Age and NIHSS) scores.

Conclusions

This proposed nomogram based on the score of CDS, the global burden of CSVD, NIHSS score ≥ 13, and OTT ≥ 180 gives rise to a more accurate and more comprehensive prediction for HT in patients with ischemic stroke receiving IV rt-PA treatment.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12883-020-02002-w.

Incidence and Prognostic Impact of Intracranial Hemorrhage after Endovascular Treatment for Acute Large Vessel Occlusion

INTRODUCTION

Endovascular treatment (EVT) is effective against acute cerebral large vessel occlusion (LVO). However, it has been associated with a high incidence of intracranial hemorrhage (ICH). Because the incidence of ICH and prognostic impact of ICH were not scrutinized in general patients, we investigated the impact of ICH after EVT on functional outcome at 90 days in patients with acute LVO.

METHODS

RESCUE-Japan Registry 2 was a multicenter registry that enrolled 2,420 consecutive patients with acute LVO within 24 h of onset. We analyzed 1,281 patients who received EVT and compared the functional outcomes between those with and without ICH (ICH and no-ICH groups, respectively) within 24 h after EVT. We explored the factors associated with ICH and prognostic impact of symptomatic ICH (SICH) among patients with ICH. We estimated the adjusted odds ratios (ORs) for good functional outcome as modified Rankin Scale scores 0-2 and mortality. We also explored the prognostic impact of symptomatic ICH (SICH) among patients with ICH.

RESULTS

ICH occurred in 333 patients (26.0%). Several factors such as perioperative edaravone, stent retriever, and baseline glucose were associated with development of ICH within 24 h. A good outcome was observed in 80 (24.0%) and 454 (47.9%) patients in the ICH and no-ICH groups, respectively, and the adjusted OR was 0.3 (95% confidence interval [CI] = 0.2-0.5, p < 0.0001). Incidence of mortality within 90 days was not significantly different between the groups (adjusted OR 1.2; 95% CI: 0.7-1.9, p = 0.5). SICH was observed in 36 (10.8%) of 333 patients with ICH, and the good outcomes were 8.3 and 25.9% in patients with SICH and asymptomatic ICH (AICH), respectively (p = 0.02). Mortality at 90 days was 30.6 and 7.1% in patients with SICH and AICH, respectively (p < 0.0001).

CONCLUSIONS

The functional outcomes at 90 days were significantly worse in patients who developed ICH after receiving EVT for acute LVO, but the mortality was generally similar.

Thrombolysis and bridging therapy in patients with acute ischaemic stroke and Covid-19

BACKGROUND AND PURPOSE

Comorbidity of acute ischaemic stroke with Covid-19 is a challenging condition, potentially influencing the decision of whether to administer intravenous thrombolysis (IVT). We aimed to assess the 1-month outcome in ischaemic stroke patients with Covid-19 infection who received IVT alone or before thrombectomy (bridging therapy).

METHODS

As a collaboration initiative promoted by the Italian Stroke Organization, all Italian stroke units (n = 190) were contacted and invited to participate in data collection on stroke patients with Covid-19 who received IVT.

RESULTS

Seventy-five invited centers agreed to participate. Thirty patients received IVT alone and 17 received bridging therapy between 21 February 2020 and 30 April 2020 in 20 centers (n = 18, Northern Italy; n = 2, Central Italy). At 1 month, 14 (30.4%) patients died and 20 (62.5%) survivors had a modified Rankin Scale (mRS) score of 3 to 5. At 24 to 36 hours, asymptomatic intracerebral hemorrhage (ICH) was reported in eight (17.4%) patients and symptomatic ICH (sICH) in two (4.3%) patients. Causes of death were severe ischaemic stroke (n = 8), a new ischaemic stroke (n = 2), acute respiratory failure (n = 1), acute renal failure (n = 1), acute myocardial infarction (n = 1), and endocarditis (n = 1). In survivors with a 1-month mRS score of 3 to 5, baseline glucose level was higher, whereas endovascular procedure time in cases of bridging therapy was longer. Baseline National Institutes of Health Stroke Scale glucose and creatinine levels were higher in patients who died.

CONCLUSIONS

Intravenous thrombolysis for patients with stroke and Covid-19 was not a rare event in the most affected areas by pandemic, and rates of 1-month unfavorable outcomes were high compared to previous data from the pre-Covid-19 literature. However, risk of sICH was not increased.

Nomogram predicting early neurological improvement in ischaemic stroke patients treated with endovascular thrombectomy

BACKGROUND AND PURPOSE

Early neurological improvement (ENI) after endovascular thrombectomy (EVT) has been associated with favorable outcomes. This study aimed to identify the optimal definition of ENI and develop a nomogram for predicting ENI after EVT in acute ischaemic stroke.

METHODS

Patients with EVT were enrolled from a multicenter registry as the training cohort. The receiver operating characteristic curve was used to estimate the optimal threshold for ENI at 24 h of EVT. Logistic regression analysis was utilized to generate the best-fit nomogram for predicting ENI. The discrimination of the nomogram was assessed using the area under the receiver operating characteristic curve (AUC). An additional 447 patients from two stroke centers were prospectively recruited as the test cohort for validating the nomogram.

RESULTS

A total of 612 patients with EVT were included in the training cohort. The optimal threshold for predicting 3-month favorable outcome (modified Rankin Scale 0-2) was an improvement of the National Institutes of Health Stroke Scale (NIHSS) score by ≥6 points (AUC 0.875; sensitivity 79.5%; specificity 90.7%). Age, blood glucose, recanalization, symptomatic intracranial hemorrhage (sICH) and baseline Alberta Stroke Program Early Computed Tomography Score (ASPECTS) were independently associated with ENI, and were incorporated in the nomogram. The AUC of the nomogram was 0.795 in the training cohort and 0.752 in the test cohort.

CONCLUSIONS

A reduction of NIHSS score ≥6 appeared to be the optimal definition of ENI. The nomogram composed of age, blood glucose, recanalization, sICH and baseline ASPECTS may predict the probability of ENI in ischaemic stroke patients treated with EVT.

Predictive Factors and Nomogram to Evaluate the Risk of Symptomatic Intracerebral Hemorrhage for Stroke Patients Receiving Thrombectomy

BACKGROUND

Symptomatic intracerebral hemorrhage (sICH) is a severe complication of mechanical thrombectomy (MT). This study is to identify predictive factors and create a nomogram to evaluate the risk of sICH after MT treatment.

METHODS

We conducted a retrospective analysis on 127 consecutive stroke patients treated by MT therapy. We evaluated multiple predictive factors for the incidence of sICH using univariate and multivariate logistic regressions. Based on the identified and other possible factors, a nomogram was constructed to predict the risk of sICH.

RESULTS

We identified several predictive factors for sICH in the univariate analysis, including thrombectomy maneuvers >3 (odds ratio [OR], 4.42; 95% confidence interval [CI], 1.25-15.6; P = 0.0211), admission blood glucose (OR, 1.29; 95% CI, 1.13-1.48; P = 0.0002), diabetes mellitus (OR, 4.44; 95% CI, 1.64-12.0; P = 0.0033), and admission National Institutes of Health Stroke Scale (NIHSS) score (OR, 1.05; 95% CI, 1.01-1.10; P = 0.0263). The multivariate analysis showed that admission NIHSS score and blood glucose significantly affected the prognosis. Moreover, the proposed nomogram showed reliable identification ability with an area under the curve of 0.82 (95% CI, 0.71-0.93), specificity of 0.745, sensitivity of 0.762, accuracy of 0.748, and negative predictive value of 0.941.

CONCLUSIONS

Our study identified the admission NIHSS score and admission blood glucose level as predictive factors for sICH. Moreover, the proposed nomogram based on possible factors showed reliable predictive performance in evaluating the risk of sICH.

Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy in Chinese Ischemic Stroke Patients: The ASIAN Score

BACKGROUND AND PURPOSE

Symptomatic intracranial hemorrhage (sICH), potentially associated with poor prognosis, is a major complication of endovascular thrombectomy (EVT) for ischemic stroke patients. We aimed to develop and validate a risk model for predicting sICH after EVT in Chinese patients due to large-artery occlusions in the anterior circulation.

METHODS

The derivation cohort recruited patients with EVT from the Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke Registry in China. sICH was diagnosed according to the Heidelberg Bleeding Classification within 24 hours of EVT. Stepwise logistic regression was performed to derive the predictive model. The discrimination and calibration of the risk model were assessed using the C index and the calibration plot. An additional cohort of 503 patients from 2 stroke centers was prospectively enrolled to validate the new model.

RESULTS

We enrolled 629 patients who underwent EVT as the derivation cohort, among whom 87 developed sICH (13.8%). In the multivariate adjustment, Alberta Stroke Program Early CT Score (odds ratio [OR], 0.85; P=0.005), baseline glucose (OR, 1.13; P=0.001), poor collateral circulation (OR, 3.06; P=0.001), passes with retriever (OR, 1.52; P=0.001), and onset-to-groin puncture time (OR, 1.79; P=0.024) were independent factors of sICH and were incorporated as the Alberta Stroke Program Early CT Score, Baseline Glucose, Poor Collateral Circulation, Passes With Retriever, and Onset-to-Groin Puncture Time (ASIAN) score. The ASIAN score demonstrated good discrimination in the derivation cohort (C index, 0.771 [95% CI, 0.716-0.826]), as well as the validation cohort (C index, 0.758 [95% CI, 0.691-0.825]).

CONCLUSIONS

The ASIAN score reliably predicts the risk of sICH in Chinese ischemic stroke patients treated by EVT.

General Anesthesia Versus Conscious Sedation and Local Anesthesia During Thrombectomy for Acute Ischemic Stroke

Background and Purpose:

As numerous questions remain about the best anesthetic strategy during thrombectomy, we assessed functional and radiological outcomes in stroke patients treated with thrombectomy in presence of general anesthesia (GA) versus conscious sedation (CS) and local anesthesia (LA).

Methods:

We conducted a cohort study on prospectively collected data from 4429 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke.

Results:

GA was used in 2013 patients, CS in 1285 patients, and LA in 1131 patients. The rates of 3-month modified Rankin Scale score of 0–1 were 32.7%, 33.7%, and 38.1% in the GA, CS, and LA groups: GA versus CS: odds ratios after adjustment for unbalanced variables (adjusted odds ratio [aOR]), 0.811 (95% CI, 0.602–1.091); and GA versus LA: aOR, 0.714 (95% CI, 0.515–0.990). The rates of modified Rankin Scale score of 0–2 were 42.5%, 46.6%, and 52.4% in the GA, CS, and LA groups: GA versus CS: aOR, 0.902 (95% CI, 0.689–1.180); and GA versus LA: aOR, 0.769 (95% CI, 0.566–0.998). The rates of 3-month death were 21.5%, 19.7%, and 14.8% in the GA, CS, and LA groups: GA versus CS: aOR, 0.872 (95% CI, 0.644–1.181); and GA versus LA: aOR, 1.235 (95% CI, 0.844–1.807). The rates of parenchymal hematoma were 9%, 12.6%, and 11.3% in the GA, CS, and LA groups: GA versus CS: aOR, 0.380 (95% CI, 0.262–0.551); and GA versus LA: aOR, 0.532 (95% CI, 0.337–0.838). After model of adjustment for predefined variables (age, sex, thrombolysis, National Institutes of Health Stroke Scale, onset-to-groin time, anterior large vessel occlusion, procedure time, prestroke modified Rankin Scale score of <1, antiplatelet, and anticoagulant), differences were found also between GA versus CS as regards modified Rankin Scale score of 0–2 (aOR, 0.659 [95% CI, 0.538–0.807]) and GA versus LA as regards death (aOR, 1.413 [95% CI, 1.095–1.823]).

Conclusions:

GA during thrombectomy was associated with worse 3-month functional outcomes, especially when compared with LA. The inclusion of an LA arm in future randomized clinical trials of anesthesia strategy is recommended.

Nomogram to Predict Mortality of Endovascular Thrombectomy for Ischemic Stroke Despite Successful Recanalization

Background

The trajectory of ischemic stroke patients attributable to large vessel occlusion is fundamentally altered by endovascular thrombectomy. This study aimed to develop a nomogram for predicting 3‐month mortality risk in patients with ischemic stroke attributed to artery occlusion in anterior circulation who received successful endovascular thrombectomy treatment.

Methods and Results

Patients with successful endovascular thrombectomy (modified Thrombolysis in Cerebral Infarction IIb or III) were enrolled from a multicenter registry as the training cohort. Step‐wise logistic regression with Akaike information criterion was utilized to establish the best‐fit nomogram. The discriminative value of the nomogram was tested by concordance index. An additional 224 patients from 2 comprehensive stroke centers were prospectively recruited as the test cohort for validating the new nomogram. Altogether, 417 patients were enrolled in the training cohort. Age (odds ratio [OR], 1.07; 95% CI, 1.03−1.10), poor pretreatment collateral status (OR, 2.13; 95% CI, 1.18−3.85), baseline blood glucose level (OR, 1.12; 95% CI, 1.04−1.21), symptomatic intracranial hemorrhage (OR, 9.51; 95% CI, 4.54−19.92), and baseline National Institutes of Health Stroke Scale score (OR, 1.08; 95% CI, 1.03−1.12) were associated with mortality and were incorporated in the nomogram. The c‐index of the nomogram was 0.835 (95% CI, 0.785–0.885) in the training cohort and 0.758 (95% CI, 0.667–0.849) in the test cohort.

Conclusions

The nomogram, composed of age, pretreatment collateral status, baseline blood glucose level, symptomatic intracranial hemorrhage, and baseline National Institutes of Health Stroke Scale score, may predict risk of mortality in patients with ischemic stroke and treated successfully with endovascular thrombectomy.

Relationship between reperfusion and intracranial hemorrhage after thrombectomy

Introduction

Symptomatic intracerebral hemorrhage (sICH) is a devastating complication after endovascular thrombectomy. Prior reports have demonstrated that thrombolysis in cerebral infarction (TICI) ≥2 b reperfusion is protective against sICH. We aimed to further examine the relationship between reperfusion grade and sICH, to elucidate whether a difference between TICI 2b and 3 exists, and to determine whether this relationship holds true for patients undergoing delayed thrombectomy (6–24 hours).

Methods

We performed a single-center retrospective review of prospectively-recorded data for patients undergoing endovascular thrombectomy for large vessel occlusion between January 2015 and February 2018. Multivariable logistic regression analyses were performed to identify predictors of parenchymal hematoma (PH) and sICH (NINDS—National Institute of Neurological Disorders and Stroke, SITS-MOST—Safe Implementation of Thrombolysis in Stroke Monitoring Study, ECASS III—European-Australian Cooperative Acute Stroke Study III criteria) and to identify the role of reperfusion grade. This analysis was repeated for delayed thrombectomy patients.

Results

528 patients were included; mean age was 71.5% and 43% were male. Median NIHSS (National Institutes of Health Stroke Scale) and time last seen well (TLSW) to treatment were 17 and 4.8 hours, respectively. Successful recanalization was achieved in 94%. On multivariable analyses, ASPECTS (Alberta Stroke Programme Early CT Score) was a predictor of PH (OR 0.7, 95% CI 0.57 to 0.87; p=0.002) for patients achieving any reperfusion grade. For patients achieving successful reperfusion, lower ASPECTS was a predictor of PH (OR 0.73, 95% CI 0.58 to 0.91; p=0.005) and of sICH (ECASS III) (OR 0.67, 95% CI 0.45 to 0.98; p=0.04); in addition, TICI 2b as compared with TICI 3 was a predictor of PH (OR 2.1, 95% CI 1 to 4.4; p=0.04) and of sICH (NINDS) (OR 7.5, 95% CI 1 to 57; p=0.045). TLSW to treatment was not an independent predictor of PH or sICH.

Conclusion

Higher baseline ASPECTS and higher degree of reperfusion following endovascular thrombectomy is associated with reduced likelihood of PH and sICH.