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Research ArticleNeurointervention

Risk of Hemorrhagic Transformation after Mechanical Thrombectomy without versus with IV Thrombolysis for Acute Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Seyed Behnam Jazayeri, Sherief Ghozy, Lina Hemmeda, Cem Bilgin, Mohamed Elfil, Ramanathan Kadirvel and David F. Kallmes
American Journal of Neuroradiology September 2024, 45 (9) 1246-1252; DOI: https://doi.org/10.3174/ajnr.A8307
Seyed Behnam Jazayeri
aFrom the Sina Trauma and Surgery Research Center (S.B.J.), Tehran University of Medical Sciences, Tehran, Iran
bDepartment of Radiology (S.B.J., S.G., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
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  • ORCID record for Seyed Behnam Jazayeri
Sherief Ghozy
bDepartment of Radiology (S.B.J., S.G., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
cDepartment of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota
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Lina Hemmeda
eFaculty of Medicine (L.H.), University of Khartoum, Khartoum, Sudan
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Cem Bilgin
bDepartment of Radiology (S.B.J., S.G., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
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Mohamed Elfil
dDepartment of Neurological Sciences (M.E.), University of Nebraska Medical Center, Omaha, Nebraska
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Ramanathan Kadirvel
bDepartment of Radiology (S.B.J., S.G., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
cDepartment of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota
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David F. Kallmes
bDepartment of Radiology (S.B.J., S.G., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
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Abstract

BACKGROUND: When treating acute ischemic stroke due to large-vessel occlusion, both mechanical thrombectomy and intravenous (IV) thrombolysis carry the risk of intracerebral hemorrhage.

PURPOSE: This study aimed to delve deeper into the risk of intracerebral hemorrhage and its subtypes associated with mechanical thrombectomy with or without IV thrombolysis to contribute to better decision-making in the treatment of acute ischemic stroke due to large-vessel occlusion.

DATA SOURCES: PubMed, EMBASE, and Scopus databases were searched for relevant studies from inception to September 6, 2023.

STUDY SELECTION: The eligibility criteria included randomized clinical trials or post hoc analysis of randomized controlled trials that focused on patients with acute ischemic stroke in the anterior circulation. After screening 4870 retrieved records, we included 9 studies (6 randomized controlled trials and 3 post hoc analyses of randomized controlled trials) with 3241 patients.

DATA ANALYSIS: The interventions compared were mechanical thrombectomy + IV thrombolysis versus mechanical thrombectomy alone, with the outcome of interest being any form of intracerebral hemorrhage and symptomatic intracerebral hemorrhage after intervention. A common definition for symptomatic intracerebral hemorrhage was pooled from various classification systems, and subgroup analyses were performed on the basis of different definitions and anatomic descriptions of hemorrhage. The quality of the studies was assessed using the revised version of Cochrane Risk of Bias 2 assessment tool. Meta-analysis was performed using the random effects model.

DATA SYNTHESIS: Eight studies had some concerns, and 1 study was considered high risk. Overall, the risk of symptomatic intracerebral hemorrhage was comparable between mechanical thrombectomy + IV thrombolysis and mechanical thrombectomy alone (risk ratio, 1.24 [95% CI, 0.89–1.72]; P = .20), with no heterogeneity across studies. Subgroup analysis of symptomatic intracerebral hemorrhage showed a non-significant difference between 2 groups based on the National Institute of Neurological Disorders and Stroke (P = .3), the Heidelberg Bleeding Classification (P = .5), the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (P = .4), and the European Cooperative Acute Stroke Study III (P = .7) criteria. Subgroup analysis of different anatomic descriptions of intracerebral hemorrhage showed no difference between the 2 groups. Also, we found no difference in the risk of any intracerebral hemorrhage between two groups (risk ratio, 1.10 [95% CI, 1.00–1.21]; P = .052) with no heterogeneity across studies.

LIMITATIONS: There was a potential for performance bias in most studies.

CONCLUSIONS: In this systematic review and meta-analysis, the risk of any intracerebral hemorrhage and symptomatic intracerebral hemorrhage, including its various classifications and anatomic descriptions, was comparable between mechanical thrombectomy + IV thrombolysis and mechanical thrombectomy alone.

ABBREVIATIONS:

AIS
acute ischemic stroke
HBC
Heidelberg Bleeding Classification
HI
hemorrhagic infarction
ICH
intracerebral hemorrhage
IVT
intravenous thrombolysis
LVO
large-vessel occlusion
MT
mechanical thrombectomy
PH
parenchymatous hematoma
RCT
randomized clinical trial
sICH
symptomatic ICH
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American Journal of Neuroradiology: 45 (9)
American Journal of Neuroradiology
Vol. 45, Issue 9
1 Sep 2024
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Cite this article
Seyed Behnam Jazayeri, Sherief Ghozy, Lina Hemmeda, Cem Bilgin, Mohamed Elfil, Ramanathan Kadirvel, David F. Kallmes
Risk of Hemorrhagic Transformation after Mechanical Thrombectomy without versus with IV Thrombolysis for Acute Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Clinical Trials
American Journal of Neuroradiology Sep 2024, 45 (9) 1246-1252; DOI: 10.3174/ajnr.A8307

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Hemorrhagic Transformation Risk After Thrombectomy
Seyed Behnam Jazayeri, Sherief Ghozy, Lina Hemmeda, Cem Bilgin, Mohamed Elfil, Ramanathan Kadirvel, David F. Kallmes
American Journal of Neuroradiology Sep 2024, 45 (9) 1246-1252; DOI: 10.3174/ajnr.A8307
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