Asymptomatic Intracranial Hemorrhage Is Associated With Poor Outcomes After Mechanical Thrombectomy for Large Vessel Occlusion

HomeStroke: Vascular and Interventional NeurologyVol. 2, No. 6Asymptomatic Intracranial Hemorrhage Is Associated With Poor Outcomes After Mechanical Thrombectomy for Large Vessel Occlusion Open AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessLetterPDF/EPUBAsymptomatic Intracranial Hemorrhage Is Associated With Poor Outcomes After Mechanical Thrombectomy for Large Vessel Occlusion Kentaro Suzuki, MD, PhD, Yuji Matsumaru, MD, PhD, Masataka Takeuchi, MD, Masafumi Morimoto, MD, PhD, Ryuzaburo Kanazawa, MD, PhD, Yohei Takayama, MD, Yuki Kamiya, MD, PhD, Keigo Shigeta, MD, PhD, Seiji Okubo, MD, PhD, Mikito Hayakawa, MD, Norihiro Ishii, MD, PhD, Yorio Koguchi, MD, PhD, Tomoji Takigawa, MD, PhD, Masato Inoue, MD, PhD, Hiromichi Naito, MD, Takahiro Ota, MD, PhD, Teruyuki Hirano, MD, PhD, Noriyuki Kato, MD, PhD, Toshihiro Ueda, MD, PhD, Yasuyuki Iguchi, MD, PhD, Kazunori Akaji, MD, PhD, Wataro Tsuruta, MD, PhD, Kazunori Miki, MD, PhD, Shigeru Fujimoto, MD, PhD, Tetsuhiro Higashida, MD, PhD, Mitsuhiro Iwasaki, MD, Junya Aoki, MD, PhD, Yasuhiro Nishiyama, MD, PhD, Toshiaki Otsuka, MD, PhD, Kazumi Kimura, MD, PhD and for the SKIP Study Investigators Kentaro SuzukiKentaro Suzuki *Correspondence to: Kentaro Suzuki, MD, PhD, Department of Neurology, Nippon Medical School, 1‐1‐5 Sendagi, Bunkyo‐ku, Tokyo 113‐8602, Japan. E‐mail: E-mail Address: [email protected] https://orcid.org/0000-0001-7607-2607 , Department of Neurology, , Nippon Medical School, , Tokyo, , Japan, Search for more papers by this author , Yuji MatsumaruYuji Matsumaru , Division of Stroke Prevention and Treatment, , Department of Neurosurgery, , Faculty of Medicine, , University of Tsukuba, , Ibaraki, , Japan, Search for more papers by this author , Masataka TakeuchiMasataka Takeuchi , Department of Neurosurgery, , Seisho Hospital, , Kanagawa, , Japan, Search for more papers by this author , Masafumi MorimotoMasafumi Morimoto , Department of Neurosurgery, , Yokohama Shintoshi Neurosurgery Hospital, , Kanagawa, , Japan, Search for more papers by this author , Ryuzaburo KanazawaRyuzaburo Kanazawa , Department of Neurosurgery, , Nagareyama Central Hospital, , Chiba, , Japan, Search for more papers by this author , Yohei TakayamaYohei Takayama , Department of Neurology, , Akiyama Neurosurgical Hospital, , Kanagawa, , Japan, Search for more papers by this author , Yuki KamiyaYuki Kamiya , Department of Neurology, , Showa University Koto Toyosu Hospital, , Tokyo, , Japan, Search for more papers by this author , Keigo ShigetaKeigo Shigeta , Department of Neurosurgery, , National Hospital Organization Disaster Medical Center, , Tokyo, , Japan, Search for more papers by this author , Seiji OkuboSeiji Okubo , Department of Cerebrovascular Medicine, , NTT Medical Center Tokyo, , Tokyo, , Japan, Search for more papers by this author , Mikito HayakawaMikito Hayakawa , Division of Stroke Prevention and Treatment, , Department of Neurosurgery, , Faculty of Medicine, , University of Tsukuba, , Ibaraki, , Japan, Search for more papers by this author , Norihiro IshiiNorihiro Ishii , Department of Neurosurgery, , New Tokyo Hospital, , Chiba, , Japan, Search for more papers by this author , Yorio KoguchiYorio Koguchi , Department of Neurology and Neurosurgery, , Chiba Emergency Medical Center, , Chiba, , Japan, Search for more papers by this author , Tomoji TakigawaTomoji Takigawa , Department of Neurosurgery, , Dokkyo Medical University Saitama Medical Center, , Saitama, , Japan, Search for more papers by this author , Masato InoueMasato Inoue , Department of Neurosurgery, , National Center for Global Health and Medicine, , Tokyo, , Japan, Search for more papers by this author , Hiromichi NaitoHiromichi Naito , Department of Neurosurgery, , Funabashi Municipal Medical Center, , Chiba, , Japan, Search for more papers by this author , Takahiro OtaTakahiro Ota , Department of Neurosurgery, , Tokyo Metropolitan Tama Medical Center, , Tokyo, , Japan, Search for more papers by this author , Teruyuki HiranoTeruyuki Hirano , Department of Stroke and Cerebrovascular Medicine, , Kyorin University, , Tokyo, , Japan, Search for more papers by this author , Noriyuki KatoNoriyuki Kato , Department of Neurosurgery, , Mito Medical Center, , Ibaraki, , Japan, Search for more papers by this author , Toshihiro UedaToshihiro Ueda , Department of Strokology, , Stroke Center, , St. Marianna University Toyoko Hospital, , Kanagawa, , Japan, Search for more papers by this author , Yasuyuki IguchiYasuyuki Iguchi , Department of Neurology, , the Jikei University School of Medicine, , Tokyo, , Japan, Search for more papers by this author , Kazunori AkajiKazunori Akaji , Department of Neurosurgery, , Mihara Memorial Hospital, , Gunma, , Japan, Search for more papers by this author , Wataro TsurutaWataro Tsuruta , Department of Endovascular Neurosurgery, , Toranomon Hospital, , Tokyo, , Japan, Search for more papers by this author , Kazunori MikiKazunori Miki , Department of Endovascular Surgery, , Tokyo Medical and Dental University, , Tokyo, , Japan, Search for more papers by this author , Shigeru FujimotoShigeru Fujimoto , Division of Neurology, , Department of Medicine, , Jichi Medical University, , Tochigi, , Japan, Search for more papers by this author , Tetsuhiro HigashidaTetsuhiro Higashida , Department of Neurosurgery, , Nagareyama Central Hospital, , Chiba, , Japan, Search for more papers by this author , Mitsuhiro IwasakiMitsuhiro Iwasaki , Department of Neurosurgery, , Yokohama Shintoshi Neurosurgery Hospital, , Kanagawa, , Japan, Search for more papers by this author , Junya AokiJunya Aoki , Department of Neurology, , Nippon Medical School, , Tokyo, , Japan, Search for more papers by this author , Yasuhiro NishiyamaYasuhiro Nishiyama , Department of Neurology, , Nippon Medical School, , Tokyo, , Japan, Search for more papers by this author , Toshiaki OtsukaToshiaki Otsuka , Department of Hygiene and Public Health, , Nippon Medical School, , Tokyo, , Japan, Search for more papers by this author , Kazumi KimuraKazumi Kimura , Department of Neurology, , Nippon Medical School, , Tokyo, , Japan, Search for more papers by this author and for the SKIP Study Investigators Search for more papers by this author Originally published20 May 2022https://doi.org/10.1161/SVIN.121.000366Stroke: Vascular and Interventional Neurology. 2022;2:e000366Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 20, 2022: Ahead of Print Several clinical trials have demonstrated the superiority of mechanical thrombectomy (MT) for acute ischemic stroke caused by emergent large vessel occlusion. However, intracranial hemorrhage (ICH) is a common complication after MT. Symptomatic ICH occurs in 5% to 16% of patients with acute ischemic stroke after MT and is associated with poor outcomes. Although asymptomatic ICH is a more common, occurring in 30% to 40% of patients, it remains unclear whether asymptomatic ICH affects the clinical outcomes. This post hoc study aimed to investigate the clinical effects of asymptomatic ICH in patients with acute ischemic stroke treated with MT.MethodsPatient data were retrospectively collected from the SKIP1 study that was an investigator‐initiated, multicenter, randomized clinical trial (UMIN000021488). This study was performed in 23 hospital networks from January 2017 to July 2019. Among 204 patients, 7 were excluded for not having undergone MT and a premodified Rankin scale (mRS) score>2. After patient enrollment, a core imaging assessment committee independently reassessed ICH presence. Based on the SITS‐MOST (Safe Implementation of Thrombolysis in Stroke‐Monitoring Study) criteria, symptomatic ICH was defined as local or remote parenchymal hematoma type2 within as well as neurological deterioration indicated by a decrease of ≥4 points on the National Institutes of Health Stroke Scale from baseline. The main outcomes were the association between asymptomatic ICH and the clinical outcome at 90 days.First, we investigated the clinical features between symptomatic and asymptomatic ICH. Next, all patients except for those with symptomatic ICH were divided into those with favorable and those with poor outcomes (mRS scores 3–6 at 90 days). Between‐group comparisons of baseline parameters were performed. Subsequently, to investigate the independent factors associated with poor clinical outcomes, we performed multivariate logistic regression analysis to calculate the odds ratios (ORs) and 95% CIs. Age and significant parameters (P<0.1) in univariate analysis were included in this analysis.ResultsAmong 197 patients, the median age was 74 years (range, 67–79 years), 63% were men, and the median National Institutes of Health Stroke Scale score was 18 (range, 12–23). Moreover, 84 patients had any ICH (71 asymptomatic and 13 symptomatic) on computed tomography scan within 36 hours. The mRS scores at 90 days according to no ICH and asymptomatic and symptomatic ICH are shown in the Figure. Among 84 patients, symptomatic ICH showed a higher incidence of poor outcomes than patients with asymptomatic ICH (36 [51%] versus 12 [92%]; P<0.01). Among 184 patients, except for 13 patients with symptomatic ICH, poor outcome was more frequent in patients with asymptomatic ICH than in those without ICH (36 [51%] versus 32 [28%]; P<0.01). Asymptomatic ICH was associated with a poor shift in the distribution of the mRS score at 90 days (OR, 2.43; 95% CI, 1.42–4.15; P<0.01). Multivariate regression analysis, including the parameters of age, histories of hypertension and cardiovascular disease, symptomatic blood pressure at admission, National Institutes of Health Stroke Scale score at admission, Alberta Stroke Program early computed tomography score, onset to puncture time, presence of asymptomatic ICH, and prestroke mRS score without 0, revealed that asymptomatic ICH within 36 hours (OR, 3.56; 95% CI, 1.70–7.75; P<0.01) was 1 of the independent factors for poor outcome. In addition, National Institutes of Health Stroke Scale score at admission (OR, 1.08; 95% CI, 1.02–1.14; P<0.01) and prestroke mRS score without 0 (OR, 7.69; 95% CI, 2.78–25.0; P<0.01) were the independent factors for poor outcome. Download figureDownload PowerPointFigure . Functional outcome defined as modified Rankin scale (range, 0 [no symptoms]–6 [death]) at 90 days according to ICH type. aICH indicates asymptomatic intracranial hemorrhage; ICH, intracranial hemorrhage; and sICH, symptomatic intracranial hemorrhage.DiscussionThe major finding was that asymptomatic ICH as well as symptomatic ICH were associated with poor outcomes.In patients treated with MT, most reports consider that asymptomatic ICH does not affect clinical outcomes.2 However, Jiang et al suggested an association of asymptomatic ICH with worse functional outcomes.3 In addition, a retrospective analysis on consecutive patients in 13 participating institutions reported an association of any hemorrhagic transformation after MT with poor functional outcomes.4 Consistent with our findings, we found that asymptomatic ICH was associated with poor outcomes.This study has some limitations. First, alteplase is approved for administration at 0.6 mg/kg in Japan, which may influence the rate and degree of ICH. Second, this study was a post hoc analysis with a small population, which may affect the statistical validity of our conclusions.ConclusionsAmong patients with acute large vessel occlusion stroke treated with MT, asymptomatic ICH was associated with poor clinical outcomes at 90 days.Sources of FundingNone.DisclosuresDr Kimura received lecture fees from Medtronic Co. Ltd. Dr Takeuchi received lecture fees from Stryker Co. Ltd. Dr Hirano received lecture fees from Medtronic Co. Ltd. Dr Matsumaru received lecture fees from Medtronic Co. Ltd and Stryker Co. Ltd.AcknowledgmentsNone.Footnotes*Correspondence to: Kentaro Suzuki, MD, PhD, Department of Neurology, Nippon Medical School, 1‐1‐5 Sendagi, Bunkyo‐ku, Tokyo 113‐8602, Japan. E‐mail: [email protected]ac.jpReferences1 Suzuki K, Matsumaru Y, Takeuchi M, Morimoto M, Kanazawa R, Takayama Y, Kamiya Y, Shigeta K, Okubo S, Hayakawa M, et al. Effect of mechanical thrombectomy without vs with intravenous thrombolysis on functional outcome among patients with acute ischemic stroke. JAMA. 2021; 325:244–253.CrossrefMedlineGoogle Scholar2 Feldman MJ, Roth S, Fusco MR, Mehta T, Arora N, Siegler JE, Mittal S, Kirshner H, Mistry AM, Yaghi S, et al. Association of asymptomatic hemorrhage after endovascular stroke treatment with outcomes. J Neurointerv Surg. 2021; 13:1095–1098.CrossrefGoogle Scholar3 Jiang F, Zhao W, Wu C, Zhang Z, Li C, Che R, Chen J, Hu W, Song H, Duan J, et al. Asymptomatic intracerebral hemorrhage may worsen clinical outcomes in acute ischemic stroke patients undergoing thrombectomy. J Stroke Cerebrovasc Dis. 2019; 28:1752–1758.CrossrefGoogle Scholar4 Nogueira RG, Gupta R, Jovin TG, Levy EI, Liebeskind DS, Zaidat OO, Rai A, Hirsch JA, Hsu DP, Rymer MM, et al. Predictors and clinical relevance of hemorrhagic transformation after endovascular therapy for anterior circulation large vessel occlusion strokes: a multicenter retrospective analysis of 1122 patients. J Neurointerv Surg. 2015; 7:16–21.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Jhou H, Yang L, Chen P and Lee C (2022) Endovascular therapy for acute ischemic stroke in patients with active malignancy: a meta-analysis with trial sequential analysis, Journal of NeuroInterventional Surgery, 10.1136/jnis-2022-019489, (jnis-2022-019489) November 2022Vol 2, Issue 6Article InformationMetrics © 2022 The Authors. Published on behalf of the American Heart Association, Inc., and the Society of Vascular and Interventional Neurology by Wiley Periodicals LLC.This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.https://doi.org/10.1161/SVIN.121.000366 Manuscript receivedJanuary 28, 2022Manuscript acceptedApril 14, 2022Originally publishedMay 20, 2022 PDF download