title: Predictors and clinical relevance of hemorrhagic transformation after endovascular therapy for anterior circulation large vessel occlusion strokes: a multicenter retrospective analysis of 1122 patients.
abstract: OBJECTIVE
  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.
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia, USA.
authors.forename: Raul G
authors.initials: RG
authors.lastname: Nogueira
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia, USA.
authors.forename: Rishi
authors.initials: R
authors.lastname: Gupta
authors.affiliation: University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Tudor G
authors.initials: TG
authors.lastname: Jovin
authors.affiliation: SUNY Buffalo, Buffalo, New York, USA.
authors.forename: Elad I
authors.initials: EI
authors.lastname: Levy
authors.affiliation: University of California Los Angeles, Los Angeles, California, USA.
authors.forename: David S
authors.initials: DS
authors.lastname: Liebeskind
authors.affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
authors.forename: Osama O
authors.initials: OO
authors.lastname: Zaidat
authors.affiliation: University of West Virginia, Morgantown, Virginia, USA.
authors.forename: Ansaar
authors.initials: A
authors.lastname: Rai
authors.affiliation: Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Hirsch
authors.affiliation: University Hospitals of Cleveland, Cleveland, Ohio, USA.
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Hsu
authors.affiliation: Saint Luke's Stroke Institute, Kansas City, Kansas, USA.
authors.forename: Marilyn M
authors.initials: MM
authors.lastname: Rymer
authors.affiliation: Allegheny General Hospital, Pittsburgh, Pennsylvania, USA.
authors.forename: Ashis H
authors.initials: AH
authors.lastname: Tayal
authors.affiliation: University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Ridwan
authors.initials: R
authors.lastname: Lin
authors.affiliation: SUNY Buffalo, Buffalo, New York, USA.
authors.forename: Sabareesh K
authors.initials: SK
authors.lastname: Natarajan
authors.affiliation: SUNY Buffalo, Buffalo, New York, USA.
authors.forename: Ashish
authors.initials: A
authors.lastname: Nanda
authors.affiliation: Allegheny General Hospital, Pittsburgh, Pennsylvania, USA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Tian
authors.affiliation: University of California Los Angeles, Los Angeles, California, USA.
authors.forename: Qing
authors.initials: Q
authors.lastname: Hao
authors.affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
authors.forename: Junaid S
authors.initials: JS
authors.lastname: Kalia
authors.affiliation: Rush University Medical Center, Chicago, Illinois, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Chen
authors.affiliation: University of Louisville Medical Center, Louisville, Kentucky, USA.
authors.forename: Alex
authors.initials: A
authors.lastname: Abou-Chebl
authors.affiliation: Boston University School of Medicine, Boston, Massachusetts, USA.
authors.forename: Thanh N
authors.initials: TN
authors.lastname: Nguyen
authors.affiliation: Massachusetts General Hospital, Boston, Massachusetts, USA.
authors.forename: Albert J
authors.initials: AJ
authors.lastname: Yoo
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001157:Arterial Occlusive Diseases / Q000150:complications*; D002545:Brain Ischemia / Q000188:drug therapy* / Q000209:etiology; D005260:Female; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods*; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy* / Q000209:etiology; D015912:Thrombolytic Therapy / Q000009:adverse effects*; D010959:Tissue Plasminogen Activator / Q000009:adverse effects*
chemical_list: D010959:Tissue Plasminogen Activator
keywords: Hemorrhage; Stroke; Thrombectomy