Predictors of Symptomatic Intracranial Hemorrhage after Endovascular Therapy in Acute Ischemic Stroke with Large Vessel Occlusion

https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.10.015Get rights and content

Background

The symptomatic intracranial hemorrhage (SICH) is a serious complication of endovascular therapy (EVT) in acute ischemic stroke (AIS) with large vessel occlusion. We aimed to clarify the predictors of SICH after EVT in patients with internal carotid artery (ICA) or proximal M1 segment of middle cerebral artery occlusions.

Methods

Among 1442 AIS patients with large vessel occlusion admitted within 24 hours after onset between July 2010 and June 2011, 226 patients with ICA or proximal M1 occlusions were treated with EVT. SICH was defined as any type of intracranial hemorrhage with a decline in the National Institutes of Health Stroke Scale (NIHSS) score ≥4.

Results

Of the 226 patients, 204 with sufficient data were analyzed. SICH was observed in 10 patients (4.9%). Baseline NIHSS score (22 versus 17), serum glucose level (206 mg/dL versus 140 mg/dL), and prior antiplatelet therapy (60.0% versus 21.7%) were significantly higher in patients with SICH than in those without (all P < .01). With receiver operating characteristic analyses, the optimal cutoff values for predicting SICH were NIHSS score ≥19 and serum glucose ≥160 mg/dL. In multivariate analysis, glucose level ≥160 mg/dL (odds ratio: 11.89; 95% confidence interval [CI]: 2.79-65.08), prior antiplatelet therapy (odds ratio: 8.03; 95% CI: 1.83-41.70), and NIHSS score ≥19 (odds ratio: 7.78; 95% CI: 1.63-59.44) were independent predictors of SICH.

Conclusion

Hyperglycemia, prior antiplatelet therapy, and high baseline NIHSS score were associated with SICH after EVT in AIS patients with ICA or proximal M1 occlusions.

Introduction

Recently, evidence was established that endovascular therapy (EVT) was effective in acute ischemic stroke (AIS) patients with large vessel occlusion in anterior circulation.1, 2, 3, 4, 5 In patients with internal carotid artery (ICA) or middle cerebral artery M1 occlusions within 6 hours from the onset, EVT, in addition to best medical treatment including intravenous tissue plasminogen activator (IV t-PA), improves functional outcome. Because the recanalization rate by IV t-PA is low in patients with ICA occlusion6, 7 or M1 occlusion of residual length <5 mm,8 early recanalization with EVT is especially expected to improve the prognosis in these patients.

Randomized trials showed that EVT, in addition to best medical treatment, did not increase the rate of symptomatic intracranial hemorrhage (SICH). However, once SICH occurs, it has a serious impact on clinical outcome. SICH was reported to be associated with worse functional outcome and mortality after EVT.9

Although several predictors of SICH after EVT have been reported,9, 10, 11, 12 these have not been clarified in patients with acute ICA or proximal M1 occlusions. A better understanding of SICH would lead to improved treatment strategy of EVT and better outcome in patients with severe AIS.

The present study aimed to clarify predictors of SICH after EVT in patients with acute ICA or proximal M1 occlusions.

Section snippets

Patients

In the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan Registry, 1442 AIS patients with large vessel occlusions who were admitted to 84 participating medical centers within 24 hours after the onset were registered between July 1, 2010 and June 30, 2011. The details of the study design and main analysis have been reported previously.13 In this study, we evaluated 714 patients who had ICA or proximal M1 occlusions. Proximal M1 occlusion was defined as residual M1

Results

Of the 226 patients with acute ICA or proximal M1 occlusions who were treated by EVT, 204 patients with sufficient data were analyzed. The mean age was 70.7 ± 12.8 years, 60.8% were men, and the median NIHSS score was 17.5 (interquartile range: 13-22). As for devices of EVT, clot removal with Merci retriever was performed in 121 patients (59.3%), clot aspiration in 23 patients (11.3%), balloon angioplasty in 85 patients (41.7%), stenting in 26 patients (12.7%), mechanical clot disruption in 26

Discussion

This study demonstrates that hyperglycemia, prior antiplatelet therapy, and high baseline NIHSS scores are associated with SICH after EVT in AIS patients with ICA or proximal M1 occlusions, and that SICH leads to significantly poor functional outcome.

The efficacy of reperfusion therapy using IV t-PA has definitely been proven for AIS. As the risk factors of SICH after IV t-PA, high baseline NIHSS score, hyperglycemia, history of diabetes, older age, high systolic blood pressure, increased time

Acknowledgment

The authors would like to thank all the RESCUE-Japan Registry investigators.

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    Grant support: This study was partly funded by a research grant from SENSHIN Medical Research Foundation.

    Conflict of interest: Dr S Yoshimura received speakers' bureau/honorarium from Bayer, Sanofi, Boehringer-Ingelheim, and Otsuka Pharmaceutical Co, and grants from Terumo and Takeda Pharmaceutical Co. Other authors declared no potential conflict of interest with respect to the research, authorship, or publication of this article.

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