Thrombolysis Before Thrombectomy May Raise ICH Risk

TOPLINE:

Intravenous thrombolysis (IVT) before endovascular treatment (EVT) was associated with a modestly increased risk for intracranial hemorrhage (ICH) in patients with anterior circulation large vessel occlusion stroke compared to EVT alone, a new meta-analysis showed. Although symptomatic ICH and asymptomatic ICH were both associated with worse functional outcomes, the benefits from IVT alone may mitigate these risks, the researchers suggested.

METHODOLOGY:

• The meta-analysis included data for more than 2000 participants with anterior circulation large vessel occlusion stroke (median age, 71 years; 56% men) from six randomized clinical trials. The analysis compared the effect of EVT plus IVT (mostly with alteplase, n = 1160) with EVT alone (n = 1153) for an increased risk for ICH.
• Researchers evaluated ICH subtypes using the Heidelberg Bleeding Classification on follow-up MRI or CT conducted within 18-72 hours post-stroke. Some additional imaging was obtained up to 7 days post-stroke.
• The primary analysis focused on describing the profile of ICH subtypes, hemorrhage patterns, and symptomatic ICH, with the analysis adjusted for multiple baseline characteristics.
• Secondary analyses included evaluation of the effect of ICH subtypes on functional outcomes measured using the modified Rankin Scale 90 days after stroke.

TAKEAWAY:

• In all, 34% of participants developed ICH. IVT plus EVT was associated with a significantly increased rate of any ICH compared to EVT alone (36% vs 32%; adjusted odds ratio [aOR], 1.2; P = .03).
• IVT plus EVT was also linked to a higher rate of any parenchymal hematoma (PH) than EVT alone (7% vs 5%; aOR, 1.5; P = .04).
• Patients with asymptomatic ICH (adjusted common OR, 0.6; P < .001) or symptomatic ICH (adjusted common OR, 0.1; P < .001) had worse functional outcomes compared to those without ICH.
• The association between IVT and increased risk for ICH was significantly enhanced in patients with elevated baseline glucose levels (≥ 140 mg/dL; P for interaction = .007) and systolic blood pressure (≥ 140 mm Hg; P for interaction = .02).

IN PRACTICE:

“Our results indicated that IVT preceding EVT might increase not only the rate of ICH, but also its severity,” the investigators wrote, noting that it may also increase the rate of any PH.

“However, it is of note that these increases in ICH and PH, while statistically significant, are relatively modest in absolute terms,” they added.

SOURCE:

This study was led by Yu Zhou, MD, Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China. It was published online on August 11 in JAMA Neurology.

LIMITATIONS:

Heidelberg radiological bleeding patterns were missing for 52 patients. Unenhanced CT had a limited capacity to distinguish contrast staining from hemorrhage, potentially affecting the accuracy of identifying hemorrhagic infarction. Additionally, varying imaging protocols and timing across trials may have led to an underestimation of asymptomatic cases or smaller hemorrhagic transformations. Final infarct volume data and detailed information on periprocedural antithrombotics or prestroke medications were unavailable, potentially confounding hemorrhage risk. Nearly all participants received alteplase, limiting the generalizability of the findings to other thrombolytics.

DISCLOSURES:

This study was funded by Stryker, Boehringer Ingelheim, the Amsterdam University Medical Centers, the Dutch Heart Foundation, the Dutch Brain Foundation, the National Natural Science Foundation of China, and the Shanghai Health and Health Commission Talent Program. Several investigators reported having various ties with pharmaceutical and medical device companies, nonprofit research foundations, and other sources. Full details are provided in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.