The Risk of Intracranial Hemorrhage in Japanese Patients with Acute Large Vessel Occlusion; subanalysis of the RESCUE-Japan registry

https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.12.022Get rights and content

Background

Recanalization therapies such as intravenous thrombolysis (IVT) or endovascular treatment (EVT) improve acute ischemic stroke outcomes; however, they carry the risk of intracranial hemorrhage (ICH). The present study assessed the frequency and predictive factor of ICH in Japanese patients with acute large vessel occlusion.

Methods

The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Registry prospectively registered 1442 stroke patients with major vessel occlusion who were admitted to 84 Japanese stroke centers within 24 hours after onset, from July 2010 to June 2011. Among these 1442 patients, 1357 were included to evaluate the incidence rate and predictive factors of ICH within 24 hours after onset.

Results

ICH was observed in 284 (20.9%) patients. Among these patients, 46 (3.4%) had symptomatic ICH, and its incidence was higher in the recanalization therapy (IVT and/or EVT) group than in the conservative therapy group (4.5% versus 2.1%, P = .013). On multivariate analyses, symptomatic ICH was related to pretreatment antiplatelet agent use and systemic heparinization, and was related to neither IVT nor EVT.

Conclusions

Symptomatic ICH was not affected by recanalization therapy or EVT itself in Japanese patients with acute large vessel occlusion.

Introduction

Recanalization therapies including intravenous thrombolysis (IVT) and endovascular treatment (EVT) have been shown to improve the outcomes of patients with acute ischemic stroke. In particular, patients who experience a proximal intracranial occlusion and undergo EVT achieve higher recanalization rates and better outcomes than those who undergo IVT alone.1, 2, 3, 4 Despite this advantage, intracranial hemorrhage (ICH) is a feared complication of recanalization therapy for acute ischemic stroke. The reported risk of symptomatic ICH ranges from 2.7% to 6.4% in patients treated with IVT5, 6 and/or from 0% to 11.2% in patients treated with EVT.1, 2, 3, 7, 8, 9, 10

EVT might be associated with a higher risk of vascular damage and subsequent ICH because it is a mechanical maneuver in an occluded intracranial vessel. Moreover, it requires the use of antithrombotic agents to reduce periprocedural thromboembolic events but could further enhance the risk of ICH.11, 12 It is not clear whether EVT itself influences the risk of symptomatic ICH in patients with acute larger vessel occlusion.

The objective of this study was to evaluate the frequency of ICH in Japanese patients with acute large vessel occlusion and to identify the independent predictive factors of ICH using data from the nationwide Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan Registry.4

Section snippets

Patients

The RESCUE-Japan Registry is a multicenter prospective registry that evaluates the acute-phase treatment results of 1442 consecutive patients with cerebral large vessel occlusion within 24 hours of symptom onset between July 1, 2010, and June 30, 2011, in 84 stroke centers in Japan. The details of data collection and management have been published previously.4 The patients received appropriate treatments (IVT, EVT with or without IVT, or medical treatment only) chosen by the site

Results

Among the 1442 patients, we excluded 82 whose detailed ICH data had been invalid and 3 who received bypass surgery. Therefore, we assessed the incidence rate of ICH and its related factors in 1357 patients. ICH was observed in 284 (20.9%) patients. Of these patients, 238 (17.5%) had asymptomatic ICH and 46 (3.4%) had symptomatic ICH. The incidence rates of both asymptomatic ICH and symptomatic ICH are higher in the recanalization therapy (IVT and/or EVT) group than in the conservative therapy

Discussion

In this study, the frequencies of asymptomatic ICH and symptomatic ICH in Japanese patients with acute large vessel occlusion were 17.5% and 3.4%, respectively, and higher in the recanalization therapy group. However, the independent predictive factors of asymptomatic ICH were recanalization therapy, baseline NIHSS score, MCA occlusion, atrial fibrillation, and reperfusion on MRA after 24 hours, and those of symptomatic ICH were pretreatment antiplatelet therapy and systemic heparinization. Our

Conclusions

In this cohort, symptomatic ICH was not related to recanalization therapy or EVT itself in Japanese patients with acute large vessel occlusion. Recanalization therapy influences the incidence of asymptomatic ICH, but not symptomatic ICH.

Acknowledgment

The authors would like to thank all the RESCUE-Japan Registry investigators. The authors also thank to Miss Kiyono Tanaka for her technical assistance.

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  • The safety and efficacy of periprocedural intravenous anticoagulants for acute ischemic stroke patients who underwent endovascular treatment: Sub-analysis of the RESCUE-Japan Registry 2

    2022, Journal of the Neurological Sciences
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    The main finding of this study is that periprocedural use of anticoagulant therapy did not affect the outcomes at 90 days or the incidence of ICH. Several reports have discussed the use of anticoagulant therapy during EVT for LVO [7–11]. Hebert et al. reported that intraoperative anticoagulant therapy for patients who received EVT without alteplase, and anticoagulant therapy reduced symptomatic hemorrhage but led to worsened the outcomes and complete reperfusion [8].

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

    2017, Journal of Stroke and Cerebrovascular Diseases
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    Prior antiplatelet therapy is a risk factor of SICH after IV t-PA, but the excess of SICH is small compared with the benefit of thrombolysis.24 In the subanalysis of RESCUE-Japan Registry, pretreatment antiplatelet agent use related to SICH in AIS patients with large vessel occlusion.25 Cucchiara et al showed that dual antiplatelet therapy brought higher risk of SICH than single antiplatelet therapy after IV t-PA.26 We did not separately analyze the association between single or dual antiplatelet therapy and the risk of SICH, because the number of patients with SICH was small in our study.

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

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