Higher Risk for Symptomatic Intracranial Hemorrhage After Endovascular Treatment for Stroke

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The rates of symptomatic intracranial hemorrhage reported by previous studies were obtained from overwhelmingly white study populations that did not take potential racial variations into account.
The rates of symptomatic intracranial hemorrhage reported by previous studies were obtained from overwhelmingly white study populations that did not take potential racial variations into account.

Risk for symptomatic intracranial hemorrhage (SICH) after endovascular treatment for acute ischemic stroke is significantly higher in real-world practice than rates reported by clinical trials, particularly in Asian patients, according to research published in Stroke.1

The multicenter study reported that SICH among Asian patients was nearly 4 times that of the rate reported by randomized controlled trials2 and was associated with greater mortality and morbidity at 90 days postprocedure.

Yonggang Hao, MD, from the Department of Neurology, Jinling Hospital, Southern Medical University (Guangzhou), Nanjing, China, and colleagues enrolled 632 patients treated in 21 stroke centers across 10 provinces in China who were registered to the ACTUAL acute ischemic stroke registry between January 2014 and June 2016.

All patients had all been treated with stent-like retrievers for recanalization of a blocked anterior artery. Of the total cohort, 101 (16.0%) experienced events classified as SICH by the new Heidelberg Bleeding Classification system within 72 hours of endovascular treatment. Patients diagnosed with SICH were much more likely to die within 90 days of treatment compared with those without SICH (65.3% vs 18.8%; P <.001), and had far fewer favorable neurologic outcomes to treatment (8.9% vs 51.2%; P <.001).

A number of factors were associated with higher risk for SICH in the cohort, including cardioembolic stroke type, poor collateral circulation, delay of treatment, multiple passes with retriever devices, lower ASPECTS, and higher neutrophil ratio at baseline.

Multiple passes of endovascular retriever devices were more frequently recorded in the Hao study than in other non-Asian cohorts, which the authors believed increased the rate of SICH because of the higher prevalence of intracranial atherosclerosis in Asian patients.3 They suggested that, because of the presence of stenosis, recanalization of atherosclerotic occlusions may present higher risk for vessel damage from the procedure than cardioembolic occlusions.

"This may explain why multiple passes with retrievers were more frequently attempted in this study (15.0%) than in North American Solitaire Acute Stroke (6.3%), and why SICH incidence (16.0%) was higher in this patient cohort," they wrote.

Compared with other studies, the SICH rate in the Hao study was significantly higher, by nearly 4 times, than the 4.4% reported in a randomized controlled trial by Goyal et al2 in 2016.

The authors observed that the rates of SICH reported by previous studies were obtained from overwhelmingly white study populations that did not take potential racial variations into account.2,4 They concluded that the real-world incidence of SICH after endovascular treatment for acute stroke is likely to be significantly higher than those reported in clinical trials, particularly in Asian patients.

References

  1. Hao Y, Yang D, Wang H, et al. Predictors for symptomatic intracranial hemorrhage after endovascular treatment of acute ischemic stroke. Stroke. 2017;48:1203-1209.  doi: 10.1161/STROKEAHA.116.016368
  2. Goyal M, Menon BK, van Zwam WH, et al. HERMES Collaborators. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387:1723-1731.
  3. Wong KS, Huang YN, Yang HB, et al. A door-to-door survey of intracranial atherosclerosis in Liangbei County, China. Neurology. 2007;68:2031-2034. doi: 10.1212/01.wnl.0000264426.63544.ee
  4. Bracard S, Ducrocq X, Mas JL, et al. THRACE Investigators. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomized controlled trial. Lancet Neurol. 2016;15:1138-1147. doi: 10.1016/S1474-4422(16)30177-6
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