Stroke

Lessons from the Chinese registry study are the importance of pretreatment risk assessment as well as the need for speedy treatment, researchers say.

Various risk factors up the likelihood that patients treated for stroke using stent retrievers will develop symptomatic intracranial hemorrhage, according to new Chinese registry data. Its authors suggest that identifying high-risk patients and taking precautions such as minimizing treatment delays and the number of passes could help reduce hemorrhage rates.

High neutrophil count, cardioembolic stroke, and poor collateral circulation are all linked to higher odds of the complication, they report.

“Hemorrhage after thrombectomy poses a major risk for patients with ischemic stroke,” lead author Yonggang Hao, MD, and senior author Gelin Xu, MD, PhD (Jinling Hospital, Southern Medical University, Nanjing, China), wrote in a joint email to Neurovascular Exchange. To identify the major risk factors for hemorrhage, Hao and colleagues analyzed data from the ACTUAL registry on 632 stroke patients who were treated with stent retrievers for recanalization of a blocked artery in the anterior circulation at one of 21 stroke centers in China. Their findings were recently published online ahead of the May 2017 issue of Stroke.

Overall, 101 of the 632 patients (16.0%) experienced a symptomatic intracranial hemorrhage, based on the Heidelberg Bleeding Classification system, within 72 hours after endovascular treatment. Symptomatic hemorrhage carried a substantially higher 90-day mortality rate (65.3% vs. 18.8%, P < 0.001).

Multivariate analysis revealed that baseline neutrophil ratio > 0.83, pretreatment ASPECTS < 6, cardioembolic stroke, poor collateral circulation, delay > 270 minutes from symptom onset to groin puncture, and more than three passes with a stent retriever were all independently associated with symptomatic hemorrhage.

Independent Predictors of Symptomatic Intracranial Hemorrhage

Preprocedural Risk Assessment Is Key

Based on these findings, Hao and Xu recommend that preprocedure stroke assessment be expanded to include these risk factors. In addition, “extra caution should be taken when treating these patients with stent-like retrievers. Patients with large artery occlusions due to intracranial atherosclerosis should not [undergo] multiple passes,” they advise, further noting that the “results also support efforts to minimize delays for treatment. This is especially important for patients with cardioembolic stroke. Due to fast occlusion of the artery, cardioembolic stroke usually has a smaller penumbra and a larger core infarct.”

As to the generalizability of the results, the researchers told NVX that “intracranial atherosclerosis is more prevalent in Asians, so the proportion of stroke due to intracranial atherosclerosis is higher in Asian patients. Intracranial atherosclerosis may challenge the passage of the retriever devices to the targeting lesions, and increase the likelihood of blood vessel injury and the risk of intracranial hemorrhage.”

They anticipate, however, that despite the approximately 20% greater prevalence of intracranial atherosclerosis among Asians, the findings should be applicable to other patient populations.

According to the authors, pretreatment assessments are vitally important to decreasing the risk of hemorrhage. But they observed that systemic assessment is often abandoned outside of clinical trials in order to minimize delays to reperfusion. A future challenge, therefore, will be to balance the need to identify high-risk patients with the need to treat them as quickly as possible. Suggesting another potential path toward improvement, they said that “development of new thrombectomy devices for artery occlusions of different etiologies may be helpful for decreasing the hemorrhage risk.”

Sources:

Hao Y, Yang D, Wang H, et al. Predictors for symptomatic intracranial hemorrhage after endovascular treatment of acute ischemic stroke. Stroke. 2017;Epub ahead of print.

Disclosures:

Xu and Hao report no relevant conflicts of interest.

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