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Original research
Risk factors and predictors of intracranial hemorrhage after mechanical thrombectomy in acute ischemic stroke: insights from the Stroke Thrombectomy and Aneurysm Registry (STAR)
  1. Natasha Ironside1,
  2. Ching-Jen Chen2,
  3. Reda M Chalhoub3,
  4. Peter Wludyka4,
  5. Ryan T Kellogg1,
  6. Sami Al Kasab5,
  7. Dale Ding6,
  8. Ilko Maier7,
  9. Ansaar Rai8,
  10. Pascal Jabbour9,
  11. Joon-tae Kim10,
  12. Stacey Q Wolfe11,
  13. Robert M Starke12,
  14. Marios-Nikos Psychogios13,
  15. Amir Shaban14,
  16. Adam S Arthur15,
  17. Shinichi Yoshimura16,
  18. Jonathan A Grossberg17,
  19. Ali Alawieh18,
  20. Isabel Fragata19,
  21. Adam J Polifka4,
  22. Justin R Mascitelli20,
  23. Joshua W Osbun21,
  24. Charles Matouk22,
  25. Michael R Levitt23,
  26. Travis M Dumont24,
  27. Hugo H Cuellar-Saenz25,
  28. Richard Williamson26,
  29. Daniele G Romano27,
  30. Roberto Javier Crosa28,
  31. Benjamin Gory29,
  32. Maxim Mokin30,
  33. Mark Moss31,
  34. Kaustubh Limaye32,
  35. Peter Kan33,
  36. Alejandro M Spiotta3,
  37. Min S Park1
  38. on behalf of the STAR collaborators
    1. 1 Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
    2. 2 Neurosurgery, University of Texas McGovern Medical School, Houston, Texas, USA
    3. 3 Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
    4. 4 Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
    5. 5 Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
    6. 6 Neurosurgery, University of Louisville, Louisville, Kentucky, USA
    7. 7 Neurology, University Medicine Goettingen, Goettingen, NS, Germany
    8. 8 Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
    9. 9 Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
    10. 10 Chonnam National University Hospital, Gwangju, Gwangju, Korea (the Republic of)
    11. 11 Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
    12. 12 Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
    13. 13 Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
    14. 14 Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
    15. 15 Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
    16. 16 Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
    17. 17 Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
    18. 18 Neurosurgery, Emory University, Atlanta, Georgia, USA
    19. 19 Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
    20. 20 Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
    21. 21 Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
    22. 22 Neurosurgery, Yale University, New Haven, Connecticut, USA
    23. 23 Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
    24. 24 Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
    25. 25 Neurosurgery, LSUHSC, Shreveport, Louisiana, USA
    26. 26 Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
    27. 27 Neurordiology, University Hospital 'San Giovanni di Dio e Ruggi d’Aragona', Salerno, Italy
    28. 28 Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
    29. 29 Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
    30. 30 Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
    31. 31 Washington Regional Medical Center, Fayetteville, Arkansas, USA
    32. 32 Indiana University, Bloomington, Indiana, USA
    33. 33 Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
    1. Correspondence to Dr Natasha Ironside, Neurosurgery, University of Virginia, Charlottesville, Virginia, USA; ironsidenatasha{at}


    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.

    • Thrombolysis
    • Thrombectomy
    • Stroke
    • Hemorrhage

    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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    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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    • Twitter @chenjared, @ChalhoubReda, @PascalJabbourMD, @Starke_neurosurgery, @ashabanmd, @AdamArthurMD, @DrMichaelLevitt, @PeterKa80460001

    • 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.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.