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Observational Study
. 2025 Jun 16;17(7):673-682.
doi: 10.1136/jnis-2024-021725.

Hemorrhagic transformation in acute ischemic stroke: hemorrhagic subtypes and symptomatic intracranial hemorrhage

Marie K Luff  1 , Nicole Khezri  1 , Salvador Miralbes  2 , Bharath Naravetla  3 , Alejandro M Spiotta  4 , Christian Loehr  5 , Mario Martínez-Galdámez  6   7 , Ryan A McTaggart  8 , Luc Defreyne  9 , Pedro Vega  10 , Osama O Zaidat  11 , Lori Lyn Price  12 , Rishi Gupta  13 , Markus A Möhlenbruch  14 , David S Liebeskind  15 ; ASSIST Investigators
Collaborators, Affiliations
Observational Study

Hemorrhagic transformation in acute ischemic stroke: hemorrhagic subtypes and symptomatic intracranial hemorrhage

Marie K Luff et al. J Neurointerv Surg. .

Abstract

Background: Few clinical studies perform detailed analyses of subtypes of intracranial hemorrhage (ICH) after mechanical thrombectomy (MT) used to treat acute ischemic stroke. Symptomatic intracranial hemorrhage (sICH) is a formidable complication of MT and is widely used in clinical trials as a safety outcome. However, variable definitions of sICH are used across clinical studies.

Objective: To radiographically subcategorize post-MT ICH development within this large cohort and examine overlap with sICH. Second, to examine the agreement of this definition of sICH with local site-reported occurrences of sICH to see how sICH rates change with modifications of the definitions used.

Methods: A large cohort of patients treated with MT for acute ischemic stroke (n=1395) was analyzed to (1) radiographically characterize hemorrhagic subtypes of intracranial hemorrhage (ICH) occurring after MT; (2) examine associations of hemorrhagic subtypes with sICH; and (3) compare core laboratory-adjudicated occurrences of sICH with site-reported sICH.

Results: The overall rate of ICH was 552/1395 patients (39.6%), and the overall rate of sICH was 47/1395 (3.4%). The most common type of ICH was hemorrhagic infarction type 1 (HI1), which represented 45.3% of all ICH cases- followed by HI2 (31.5%) and subarachnoid hemorrhage (SAH, 29.2%). Parenchymal hematoma 2 (PH2) represented only 3.3% of all ICH cases. Of the PH2 hemorrhages, only 33.3% were determined to be symptomatic. Of sICH cases, the most common ICH subtypes were HI2 (48.9%) and SAH (38.3%). Comparison of sICH rates as determined by core laboratory adjudication versus local site-reported results showed that only 14 patients were identified as having sICH with both definitions, with 47 patients total with sICH according to one definition, but not the other.

Conclusions: Results of this analysis demonstrate the radiographic subtypes of ICH and also highlight the limitations of variable criteria used to define sICH, suggesting that it might be appropriate to revisit how sICH is defined post-MT.

Trial registration number: Clinical trial NCT03845491.

Keywords: Device; Hemorrhage; Stroke; Thrombectomy.

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Conflict of interest statement

Competing interests: AMS reports consulting (paid to self) for RapidAI, Terumo, and Penumbra; research support (paid to institution) from Penumbra, RapidAI, Microvention, Stryker, and Medtronic. OOZ reports a research grant from Stryker, Medtronic, Cerenovus, Penumbra, and Genentech; he is a consultant and speaker for Cerenovus, Stryker, Penumbra, and Medtronic; has ownership interest in Galaxy Therapeutics Inc; and serves on the endovascular committee as co-chair for National Institutes of Health StrokeNet Consortium and has served as an expert witness. LLP is an employee of Stryker and holds Stryker stock). RG serves as principal investigator (PI) for the ASSIST Registry (Stryker), PI for the RECCLAIM II Study (Zoll), Clinical Events Committee (CEC) for the MIND Trial (Penumbra), Data Safety Monitoring Board (DSMB) Membrane Study (Cerenovus), ELEVATE Study (Medtronic) consultant and stock options for Vesalio, Rapid Medical. MAM received research grants from Acandis, Balt, Medtronic, Microvention, Phenox, Stryker* (*industry payments are made to the research fund of the institution), receives payment or honoraria for lectures from Balt, Medtronic, Stryker* (*industry payments are made to the research fund of the institution). DSL reports a consultant as imaging core laboratory for Cerenovus, Genentech, Medtronic, Rapid Medical, Stryker, Vesalio. All other authors report no disclosures.

Figures

Figure 1
Figure 1. Patient enrollment flowchart. ICH, intracranial hemorrhage; NIHSS, National Institutes of Health Stroke Scale.
Figure 2
Figure 2. Comparisons of NIHSS scores from baseline to 24-hour visit. (A) Any hemorrhage versus no hemorrhage. (B) HI1 with NIHSS score increase ≥4 versus HI1 with NIHSS score increase <4. (C) HI2 with NIHSS score increase ≥4 versus HI2 with NIHSS score increase <4. (D) PH1 with NIHSS score increase ≥4 versus PH1 with NIHSS score increase <4. (E) PH2 with NIHSS score increase ≥4 versus PH2 with NIHSS score increase <4. (F) SAH with NIHSS score increase ≥4 versus SAH with NIHSS score increase <4. HI1, HI2, hemorrhagic infarction types 1 and 2; SAH, subarachnoid hemorrhage; NIHSS, National Institutes of Health Stroke Scale; PH1, PH2, parenchymal hematoma 1 and 2.
See this image and copyright information in PMC

References

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