The Risk of Intracranial Hemorrhage in Japanese Patients with Acute Large Vessel Occlusion; subanalysis of the RESCUE-Japan registry
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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Cited by (18)
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 SciencesCitation Excerpt :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
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Grant support: This study was partly funded by a research grant from SENSHIN Medical Research Foundation.