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Predictors and clinical relevance of hemorrhagic transformation after endovascular therapy for anterior circulation large vessel occlusion strokes: a multicenter retrospective analysis of 1122 patients
  1. Raul G Nogueira1,
  2. Rishi Gupta1,
  3. Tudor G Jovin2,
  4. Elad I Levy3,
  5. David S Liebeskind4,
  6. Osama O Zaidat5,
  7. Ansaar Rai6,
  8. Joshua A Hirsch7,
  9. Daniel P Hsu8,
  10. Marilyn M Rymer9,
  11. Ashis H Tayal10,
  12. Ridwan Lin2,
  13. Sabareesh K Natarajan3,
  14. Ashish Nanda3,
  15. Melissa Tian10,
  16. Qing Hao4,
  17. Junaid S Kalia5,
  18. Michael Chen11,
  19. Alex Abou-Chebl12,
  20. Thanh N Nguyen13,
  21. Albert J Yoo7
  1. 1Emory University School of Medicine, Atlanta, Georgia, USA
  2. 2University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
  3. 3SUNY Buffalo, Buffalo, New York, USA
  4. 4University of California Los Angeles, Los Angeles, California, USA
  5. 5Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  6. 6University of West Virginia, Morgantown, Virginia, USA
  7. 7Massachusetts General Hospital, Boston, Massachusetts, USA
  8. 8University Hospitals of Cleveland, Cleveland, Ohio, USA
  9. 9Saint Luke's Stroke Institute, Kansas City, Kansas, USA
  10. 10Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
  11. 11Rush University Medical Center, Chicago, Illinois, USA
  12. 12University of Louisville Medical Center, Louisville, Kentucky, USA
  13. 13Boston University School of Medicine, Boston, Massachusetts, USA
  1. Correspondence to Dr R Gupta, Emory University School of Medicine, 49 Jesse Hill Dr SE, Room 393, Atlanta, GA 30303, USA; rishi.gupta{at}


Background and purpose Endovascular techniques are frequently employed to treat large artery occlusion in acute ischemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial hemorrhage (ICH) after endovascular therapy.

Methods Retrospective analysis of consecutive patients presenting to 13 high volume stroke centers with AIS due to proximal occlusion in the anterior circulation who underwent endovascular treatment within 8 h from symptom onset. Logistic regression was performed to determine the variables associated with ICH, hemorrhagic infarction (HI), and parenchymal hematomas (PHs), as well as 90 day poor outcome (modified Rankin Scale score ≥3) and mortality.

Results There were a total of 363 ICHs (overall rate 32.3%; HI=267, 24%; PH=96, 8.5%) among the 1122 study patients (mean age 67±15 years; median National Institutes of Health Stroke Scale score 17 (IQR 13–20)). Independent predictors for HI included diabetes mellitus (OR 2.27, 95% CI (1.58 to 3.26), p<0.0001), preprocedure IV tissue plasminogen activator (tPA) (1.43 (1.03 to 2.08), p<0.037), Merci thrombectomy (1.47 (1.02 to 2.12), p<0.032), and longer time to puncture (1.001 (1.00 to 1.002), p<0.026). Patients with atrial fibrillation (1.61 (1.01 to 2.55), p<0.045) had a higher risk of PH while the use of IA tPA (0.57 (0.35 to 0.90), p<0.008) was associated with lower chances of PH. Both the presence of HI (2.23 (1.53 to 3.25), p<0.0001) and PH (6.24 (3.06 to 12.75), p<0.0001) were associated with poor functional outcomes; however, only PH was associated with higher mortality (3.53 (2.19 to 5.68), p<0.0001).

Conclusions Greater understanding about the predictors and consequences of ICH post endovascular stroke therapy is essential to improve risk assessment, patient selection/clinical outcomes, and early prognostication. Our data suggest that patients with atrial fibrillation are particularly prone to severe ICH and question the ‘benign’ nature of HI suggested by earlier studies.

  • Stroke
  • Thrombectomy
  • Hemorrhage

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