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Original research
Predicting symptomatic intracranial hemorrhage in anterior circulation stroke patients with contrast enhancement after thrombectomy: the CAGA score
  1. Guo-Can Chang1,
  2. Thanh N Nguyen2,
  3. Jing Qiu1,
  4. Wei Li1,
  5. Yong-Gang Zhao1,
  6. Xian-Hui Sun1,
  7. Xin Liu1,
  8. Zi-Ai Zhao1,
  9. Liang Liu1,
  10. Mohamad Abdalkader3,
  11. Hui-Sheng Chen1
  1. 1 Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, Liaoning, China
  2. 2 Neurology, Boston Medical Center, Boston, Massachusetts, USA
  3. 3 Radiology, Boston Medical Center, Boston, Massachusetts, USA
  1. Correspondence to Dr Hui-Sheng Chen, Department of Neurology, General Hospital of Northern Theatre command, Shenyang, Liaoning, 110017, China; chszh{at}


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.

  • Stroke
  • Thrombectomy
  • Hemorrhage

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors G-CC retrospectively enrolled patients, acquired the data, and did the literature search. JQ, LL, X-HS, Y-GZ, XL, Z-AZ, and LL acquired the data. G-CC did the statistical analysis and wrote the draft. WL and JQ analyzed the imaging data. TNN and MA critically revised the manuscript. H-SC provided substantial contribution to the design of the study and critically revised the manuscript; had access to the data; approved final version to be published; and agreed to be accountable for all aspects of the work to ensure all questions related to the accuracy or integrity of any aspect of the work are investigated and resolved.

  • Funding The work was supported by the Science and Technology Plan of Shen Yang (20-205-4-007) and the Science and Technology Project Plan of Liao Ning Province (2020JH1/10300002).

  • Competing interests None declared.

  • 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.