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Symptomatic intracerebral hemorrhage in proximal and distal medium middle cerebral artery occlusion patients treated with mechanical thrombectomy
  1. Vivek S Yedavalli1,
  2. Hamza Adel Salim1,2,
  3. Basel Musmar3,
  4. Nimer Adeeb3,
  5. Muhammed Amir Essibayi4,
  6. Kareem ElNaamani4,
  7. Nils Henninger5,6,
  8. Sri Hari Sundararajan7,
  9. Anna Luisa Kuhn8,
  10. Jane Khalife9,
  11. Sherief Ghozy10,
  12. Luca Scarcia11,
  13. Benjamin YQ Tan12,13,
  14. Jeremy Josef Heit14,
  15. Robert W Regenhardt2,
  16. Nicole M Cancelliere15,
  17. Joshua D Bernstock16,
  18. Aymeric Rouchaud17,
  19. Jens Fiehler18,
  20. Sunil A Sheth19,
  21. Ajit S Puri8,
  22. Christian Dyzmann20,
  23. Marco Colasurdo21,
  24. Xavier Barreau22,
  25. Leonardo Renieri23,
  26. João Pedro Filipe24,
  27. Pablo Harker25,
  28. Răzvan Alexandru Radu26,
  29. Thomas R Marotta15,
  30. Julian Spears15,
  31. Takahiro Ota27,
  32. Ashkan Mowla28,
  33. Pascal Jabbour5,
  34. Arundhati Biswas29,
  35. Frédéric Clarençon30,31,
  36. James E Siegler9,
  37. Thanh N Nguyen32,
  38. Ricardo Varela33,
  39. Amanda Baker4,
  40. David Altschul4,
  41. Nestor Gonzalez34,
  42. Markus A Möhlenbruch35,
  43. Vincent Costalat26,
  44. Benjamin Gory36,37,
  45. Paul Stracke38,
  46. Mohammad Ali Aziz-Sultan16,
  47. Constantin Hecker39,
  48. Hamza Shaikh9,
  49. David S Liebeskind40,
  50. Alessandro Pedicelli41,
  51. Andrea M Alexandre41,
  52. Illario Tancredi42,
  53. Tobias D Faizy18,
  54. Erwah Kalsoum11,
  55. Boris Lubicz43,
  56. Aman B Patel2,
  57. Vitor Mendes Pereira15,
  58. Adrien Guenego43,
  59. Adam A Dmytriw2,15
  60. the MAD MT Investigators
    1. 1Department of Radiology, Division of Neuroradiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
    2. 2Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
    3. 3Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, Louisiana, USA
    4. 4Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
    5. 5Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
    6. 6Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
    7. 7Department of Endovascular Neurosurgery and Neuroradiology, NJMS, Newark, New Jersey, USA
    8. 8Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
    9. 9Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, New Jersey, USA
    10. 10Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, Minnesota, USA
    11. 11Department of Neuroradiology, Henri Mondor Hospital, Creteil, France
    12. 12Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
    13. 13Division of Neurology, Department of Medicine, National University Hospital, Singapore
    14. 14Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, California, USA
    15. 15Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
    16. 16Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
    17. 17University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
    18. 18Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
    19. 19Department of Neurology, UTHealth McGovern Medical School, Houston, Texas, USA
    20. 20Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Schleswig-Holstein, Germany
    21. 21Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA
    22. 22Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
    23. 23Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
    24. 24Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
    25. 25Department of Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
    26. 26Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
    27. 27Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
    28. 28Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine University of Southern California (USC), Los Angeles, California, USA
    29. 29Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
    30. 30GRC BioFast, Sorbonne Université, Paris, France
    31. 31Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
    32. 32Departments of Radiology & Neurology, Boston Medical Center, Boston, Massachusetts, USA
    33. 33Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal
    34. 34Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
    35. 35Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
    36. 36Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France
    37. 37INSERM U1254, IADI, Université de Lorraine, Vandœuvre-lès-Nancy, France
    38. 38Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany
    39. 39Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
    40. 40UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, California, USA
    41. 41UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
    42. 42Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
    43. 43Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
    1. Correspondence to Dr Hamza Adel Salim; hamza.sleeem{at}


    Background Acute ischemic stroke (AIS) caused by distal medium vessel occlusions (DMVOs) represents a significant proportion of overall stroke cases. While intravenous thrombolysis (IVT) has been a primary treatment, advancements in endovascular procedures have led to increased use of mechanical thrombectomy (MT) in DMVO stroke patients. However, symptomatic intracerebral hemorrhage (sICH) remains a critical complication of AIS, particularly after undergoing intervention. This study aims to identify factors associated with sICH in DMVO stroke patients undergoing MT.

    Methods This retrospective analysis utilized data from the Multicenter Analysis of Distal Medium Vessel Occlusions: Effect of Mechanical Thrombectomy (MAD-MT) registry, involving 37 centers across North America, Asia, and Europe. Middle cerebral artery (MCA) DMVO stroke patients were included. The primary outcome measured was sICH, as defined per the Heidelberg Bleeding Classification. Univariable and multivariable logistic regression were used to identify factors independently associated with sICH.

    Results Among 1708 DMVO stroke patients, 148 (8.7%) developed sICH. Factors associated with sICH in DMVO patients treated with MT included older age (adjusted odds ratio (aOR) 1.01, 95% confidence interval (95% CI) 1.00 to 1.03, P=0.048), distal occlusion site (M3, M4) compared with medium occlusions (M2) (aOR 1.71, 95% CI 1.07 to 2.74, P=0.026), prior use of antiplatelet drugs (aOR 2.06, 95% CI 1.41 to 2.99, P<0.001), lower Alberta Stroke Program Early CT Scores (ASPECTS) (aOR 0.75, 95% CI 0.66 to 0.84, P<0.001), higher preoperative blood glucose level (aOR 1.00, 95% CI 1.00 to 1.01, P=0.012), number of passes (aOR 1.27, 95% CI 1.15 to 1.39, P<0.001), and successful recanalization (Thrombolysis In Cerebral Infarction (TICI) 2b-3) (aOR 0.43, 95% CI 0.28 to 0.66, P<0.001).

    Conclusion This study provides novel insight into factors associated with sICH in patients undergoing MT for DMVO, emphasizing the importance of age, distal occlusion site, prior use of antiplatelet drugs, lower ASPECTS, higher preoperative blood glucose level, and procedural factors such as the number of passes and successful recanalization. Pending confirmation, consideration of these factors may improve personalized treatment strategies.

    • Stroke

    Data availability statement

    Data are available upon reasonable request. The data supporting this study’s findings are available from the corresponding author upon reasonable request.

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    Data availability statement

    Data are available upon reasonable request. The data supporting this study’s findings are available from the corresponding author upon reasonable request.

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    • VSY and HAS are joint first authors.

    • HAS and AAD are joint senior authors.

    • X @vsyedavalli, @hamza_isleem, @MAEssibayi, @kareemnaamaniMD, @NMCancelliere, @Fie0815, @AjitSPuri1, @Taka_Tamaso, @PascalJabbourMD, @JimSiegler, @NguyenThanhMD, @DavidAltschulMD, @VitorMendesPer1, @GuenegoAdrien, @AdamDmytriw

    • VSY and HAS contributed equally.

    • Collaborators MAD MT Investigators. Abdelaziz Amllay MD1, Achala Vagal MD2, Adrien ter Schiphorst MD3, Ajith J Thomas MD4, Anil Gopinathan5, Anne Dusart MD6, Carolina Capirossi MD7, Charbel Mounayer MD8, Charlotte Weyland MD9, Cheng-Yang Hsieh MD10, Christoph J Griessenauer MD11, Christopher J Stapleton MD12, Erwah Kalsoum MD13, Flavio Bellante MD6, Gaultier Marnat MD14, Géraud Forestier MD8, Hamza Shaikh MD15, Hugo H Cuellar-Saenz MD12, Iacopo Valente MD16, Igor Sibon MD PhD17, James D Rabinov MD12, Jérôme Berge MD14, Jessica Jesser MD9, Juan Carlos Martinez-Gutierrez MD18, Kevin Premat MD19, Leonard LL Yeo MD PhD5, Lina Chervak MD2, Lukas Meyer MD20, Mahmoud Elhorany MD19, Miguel Quintero-Consuegra MD21, Mohamad Abdalkader MD22, Mohammad Ali Aziz-Sultan MD23, Monika Killer-Oberpfalzer MD11, Peter T Kan MD MPH24, Piers Klein MA22, Priyank Khandelwal MD25, Ramanathan Kadirvel PhD4, Robert Fahed MD26, Sergio Salazar-Marioni MD18, Shogo Dofuku MD27, Simona Nedelcu MD PhD28, Stavropoula I Tjoumakaris MD1, Suzana Saleme MD8, Yasmin Aziz MD29. 1 Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA; 2 Department of Neurology and Radiology, University of Cincinnati, USA; 3 Department of Neurology, Gui de Chauliac Hospital, Montpellier University Medical Center; 4 Departments of Neurological Surgery

    • Contributors All co-authors have made substantial contributions to all the categories established by the ICMJE: 1. conception, design, acquisition and interpretation of data, 2. drafting the article and revising it critically, 3. final approval of the version to be published, 4. absence of ghost writing, 5. agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. No industry support regarding this manuscript. Dr Vivek Yedavalli takes full responsibility for the data, the analyses and interpretation, and the conduct of the research. He has full access to all of the data; and has the right to publish any and all data separate and apart from any sponsor. All authors have read and approved the submitted manuscript; they have also agreed to conditions noted on the Authorship Agreement Form. The manuscript has not been submitted elsewhere nor published elsewhere in whole or in part. An IRB has approved the use of humans for this study.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests Dr Regenhardt serves on a DSMB for a trial sponsored by Rapid Medical, serves as site PI for studies sponsored by Penumbra and Microvention, and receives stroke research grant funding from the National Institutes of Health, Society of Vascular and Interventional Neurology, and Heitman Stroke Foundation. Dr Guenego reports consultancy for Rapid Medical and Phenox, not directly related to the present work. Dr Clarençon reports conflicts of interest with Medtronic, Balt Extrusion (consultant), ClinSearch (core lab), Penumbra, Stryker (payment for reading) and Artedrone (Board); all not directly related to the present work. Dr Henninger received support from W81XWH-19-PRARP-RPA from the CDMRP/DoD, NS131756 and U24NS113844 from the NINDS, and NR020231 from the NINR and received compensation from Myrobalan, Inc and General Dynamics during the conduct of this study unrelated to this work. Dr Liebeskind is consultant as Imaging Core Lab to Cerenovus, Genentech, Medtronic, Stryker, Rapid Medical. Dr Yeo reports Advisory work for AstraZeneca, substantial support from NMRC Singapore and is a medical advisor for See-mode, Cortiro and Sunbird Bio, with equity in Ceroflo; all unrelated to the present work. Dr Griessenauer reports a proctoring agreement with Medtronic and research funding by Penumbra. Dr Marnat reports conflicts of interest with Microvention Europe, Stryker Neurovascular, Balt (consulting), Medtronic, Johnson & Johnson and Phenox (paid lectures), all not directly related to the present work. Dr Puri is a consultant for Medtronic Neurovascular, Stryker Neurovascular, Balt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical, he received research grants from NIH, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular, and holds stocks in InNeuroCo, Agile, Perfuze, Galaxy and NTI. Dr Tjoumakaris is a consultant for Medtronic and Microvention (funds paid to institution, not personally). Dr Jabbour is a consultant for Medtronic, Microvention and Cerus. HS and VY are guarantors of the study.

    • Provenance and peer review Not commissioned; externally peer reviewed.