Background Reducing intracranial hemorrhage (ICH) can improve patient outcome in acute ischemic stroke (AIS) intervention. We sought to identify ICH risk factors after AIS thrombectomy.
Methods This is a retrospective review of the Stroke Thrombectomy and Aneurysm Registry (STAR) database. All patients who underwent AIS thrombectomy with available ICH data were included. Multivariable regression models were developed to identify predictors of ICH after thrombectomy. Subgroup analyses were performed stratified by symptom status and European Cooperative Acute Stroke Study (ECASS) grade.
Results The study cohort comprised 6860 patients. Any ICH and symptomatic ICH (sICH) occurred in 25% and 7% of patients, respectively. Hemorrhagic infarction 1 (HI1) occurred in 36%, HI2 in 24%, parenchymal hemorrhage 1 (PH1) in 22%, and PH2 in 17% of patients classified by ECASS grade. Intraprocedural complications independently predicted any ICH (OR 3.8083, P<0.0001), PH1 (OR 1.9053, P=0.0195), and PH2 (OR 2.7347, P=0.0004). Race also independently predicted any ICH (black: OR 0.5180, P=0.0017; Hispanic: OR 0.4615, P=0.0148), sICH (non-white: OR 0.4349, P=0.0107), PH1 (non-white: OR 3.1668, P<0.0001), and PH2 (non-white: OR 1.8689, P=0.0176), with white as the reference. Primary mechanical thrombectomy technique also independently predicted ICH. ADAPT (A Direct Aspiration First Pass Technique) was a negative predictor of sICH (OR 0.2501, P<0.0001), with stent retriever as the reference.
Conclusions This study identified ICH risk factors after AIS thrombectomy using real-world data. There was a propensity towards a reduced sICH risk with direct aspiration. Procedural complications and ethnicity were predictors congruent between categories of any ICH, sICH, PH1, and PH2. Further investigation of technique and ethnicity effects on ICH and outcomes after AIS thrombectomy is warranted.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Correction notice Since this article first published, Peter Wludyka has been added as an author.
Collaborators Marielle Ernst, MD - Universitätsmedizin Göttingen, Göttingen, Germany. Stavropoula Tjoumakaris, MD, M. Reid Gooch, MD, Nabeel Herial, MD - Thomas Jefferson University, Philadelphia, PA, USA. Kyle Fargen, MD - Wake Forest Baptist Health, Winston-Salemn, NC, USA. Dileep R. Yavagal, MD, Eric C. Peterson, MD - University of Miami Health System, Miami, FL, USA. Alex Brehm, MD - Universitätsspital Basel, Basel, Switzerland. Edgar Samaniego, MD, MS - University of Iowa, Iowa City, IA, USA. Nitin Goyal, MD, Daniel Alan Hoit, MD, MPH, Violiza Inoa-Acosta, MD - University of Tennessee Health Science Center/Semmes Murphey Foundation, Memphis, TN, USA. Michael Cawley, MD, Gustavo Pradilla, MD, Brian Howard, MD - Emory University, Atlanta, GA, USA. João Reis, MD, Jaime Pamplona, MD, Rui Carvalho, MD - Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal. Brian Hoh, MD, MBA, Nohra Chalouhi, MD- University of Florida, Gainesville, FL, USA. Ryan Hebert, MD - Yale University, New Haven, CT, USA. Louis J. Kim, MD, Melanie Walker, MD, University of Washington, Seattle, WA, USA. Russell Cerejo, MD - Alleghany Hospital, Pittsburgh, PA, USA. Giulia Frauenfelder, MD, Francesco Diana, MD - Aou S. Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy. Fernanda Rodriguez-Erazú, MD - Médica Uruguaya, Montevideo, Uruguay. Waldo Guerrero, MD - University of South Florida, Tampa, FL, USA. Mehmet Akdol, MD - Washington Regional Medical, Fayetteville, AR, USA.
Contributors Design and conception: NI, MSP. Data collection: all authors. Statistical analysis: NI, C-JC. Interpretation of results: all authors. Drafting of manuscript: all authors. Revision of manuscript: all authors. Approval of final manuscript: all authors. Study supervision: MSP, AMS.Guarantor: NI
Funding The STAR registry currently receives funding from Penumbra, Stryker and Medtronic. MRL: Grants from the NIH (R01NS105692, R01NS088072, U24NS100654, UL1TR002319, R25NS079200) and the American Heart Association (18CDA34110295). Unrestricted educational grants from Medtronic, Stryker and Philips Volcano. Consultant for Medtronic. Minor equity/ownership interest in Proprio, Cerebrotech, Synchron. Adviser to Metis Innovative. JAG: Grants from the Georgia Research Alliance. Consultant for Cognition Medical. AMS: Research support from Penumbra, Stryker, Medtronic, and Siemens. Consultant for Penumbra, Stryker, Terumo, and Arsenal. MM: Consultant for Medtronic, and Cerenovus. Stock ownership in Serenity Medical, Synchron, and Endostream. RMS: Grants from the NREF, Joe Niekro Foundation, Brain Aneurysm Foundation, Bee Foundation, the NIH (R01NS111119-01A1, UL1TR002736, KL2TR002737), the National Center for Advancing Translational Sciences, the National Institute on Minority Health and Health Disparities, and Medtronic. Consultant for Penumbra, Abbott, Medtronic, InNeuroCo and Cerenovus.
Competing interests PK, JRM, MM and MRL are members of the editorial board of JNIS.
Provenance and peer review Not commissioned; externally peer reviewed.
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