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• Analysis of Intracranial Hemorrhagic Complications in Anterior Circulation Endovascular Thrombectomy
  Mohammadreza Ahmadkhani
  Published on: 14 October 2024

• Published on: 14 October 2024

  Analysis of Intracranial Hemorrhagic Complications in Anterior Circulation Endovascular Thrombectomy

  • Mohammadreza Ahmadkhani, MD Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran

  To the Editor,

  I am writing to discuss the recent article titled "Incidence of intracranial hemorrhagic complications after anterior circulation endovascular thrombectomy in relation to occlusion site: a nationwide observational register study" (1). This study provides valuable insights into intracranial hemorrhage (ICH) as a potential complication of endovascular thrombectomy (EVT) in patients with anterior circulation vessel occlusion stroke. The authors conducted a comprehensive analysis, considering different occlusion sites and their associations with the incidence and severity of ICH, specifically symptomatic (sICH) and non-symptomatic (non-sICH) cases. While the study presents crucial findings, it is essential to discuss its implications and limitations.

  The study's key finding of a 4.5% incidence of sICH after EVT for anterior circulation vessel occlusion stroke is consistent with previous research in this area. The recognition of differences in the frequency and severity of ICH across occlusion sites, particularly in the internal carotid artery (ICA), middle cerebral artery's first segment (M1), and the M2 and beyond, is a significant contribution to our understanding of EVT outcomes. The study suggests that ICA occlusions, despite their lower overall hemorrhage frequency, tend to result in more severe ICH, including intraventricular hemorrhages and space-occupying intracerebral hemorrhages. This observation aligns with prior stud...

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  To the Editor,

  I am writing to discuss the recent article titled "Incidence of intracranial hemorrhagic complications after anterior circulation endovascular thrombectomy in relation to occlusion site: a nationwide observational register study" (1). This study provides valuable insights into intracranial hemorrhage (ICH) as a potential complication of endovascular thrombectomy (EVT) in patients with anterior circulation vessel occlusion stroke. The authors conducted a comprehensive analysis, considering different occlusion sites and their associations with the incidence and severity of ICH, specifically symptomatic (sICH) and non-symptomatic (non-sICH) cases. While the study presents crucial findings, it is essential to discuss its implications and limitations.

  The study's key finding of a 4.5% incidence of sICH after EVT for anterior circulation vessel occlusion stroke is consistent with previous research in this area. The recognition of differences in the frequency and severity of ICH across occlusion sites, particularly in the internal carotid artery (ICA), middle cerebral artery's first segment (M1), and the M2 and beyond, is a significant contribution to our understanding of EVT outcomes. The study suggests that ICA occlusions, despite their lower overall hemorrhage frequency, tend to result in more severe ICH, including intraventricular hemorrhages and space-occupying intracerebral hemorrhages. This observation aligns with prior studies and may be attributed to various factors, including the larger affected brain area and differences in vascular supply.

  The study emphasizes the complexity of managing blood pressure following EVT, as it plays a critical role in achieving optimal reperfusion while minimizing the risk of adverse events, particularly in cases involving proximal vessel occlusions. Furthermore, the authors shed light on the administration of antithrombotic medication during EVT for ICA occlusions and its potential impact on sICH. This is particularly relevant given the rising concern regarding the risk of hemorrhagic complications associated with procedural antithrombotic medication.

  The findings regarding EVT for occlusions in the M2 and beyond are promising, with a relatively lower incidence of sICH. The study suggests room for improvement in revascularization efficacy for these distal vessels. This is a significant consideration as it indicates that EVT should not be discouraged for the treatment of more distal vascular domains within the middle cerebral artery territory.

  However, it is crucial to acknowledge the study's limitations. The definition of sICH in this study differs from the Heidelberg Bleeding Classification, which may affect the frequency of sICH cases. The categorization of sICH and δ-NIHSS was not complete in the registry, which might result in an underestimation of sICH. Additionally, the use of a modified ASPECT score for the estimation of the affected brain area is subject to inherent limitations, and further research may benefit from a more precise approach.

  In conclusion, this study provides valuable insights into the incidence and severity of ICH following EVT for anterior circulation vessel occlusion stroke, with a particular focus on different occlusion sites. The findings have important implications for clinical practice, especially in managing blood pressure and antithrombotic medication during and after EVT. While the study's limitations should be considered, its contributions to our understanding of EVT outcomes are noteworthy and may guide future research in this area.
  References:
  1. Hall E, Ullberg T, Andsberg G, et alIncidence of intracranial hemorrhagic complications after anterior circulation endovascular thrombectomy in relation to occlusion site: a nationwide observational register studyJournal of NeuroInterventional Surgery Published Online First: 05 October 2023. doi: 10.1136/jnis-2023-020768

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  Conflict of Interest:
  None declared.

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