Predictors of parenchymal hemorrhage after endovascular treatment in large core ischemic stroke: a post-hoc analysis of the ANGEL-ASPECT trial

BACKGROUND: The efficacy of mechanical thrombectomy (MT) for treating large infarcts has been established through multiple recent randomized controlled trials (RCTs). Nevertheless, hemorrhagic transformation (HT) remains one of the significant challenges following thrombectomy in these patients. METHODS: This study presents a post-hoc analysis of the Study of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core (ANGEL-ASPECT) trial. We included all patients with large infarcts who underwent thrombectomy and had imaging data available for HT assessment. Multivariate regression models were developed to determine the predictive factors for post-thrombectomy parenchymal hemorrhage (PH) and examine the relationship between PH and patient outcomes. RESULTS: This study enrolled 217 patients, of whom 35 (16.1%) experienced PH 24-48 hours after thrombectomy. Multivariate analysis showed that patients with PH had a significantly worse functional outcome compared with patients without PH (modified Rankin Scale (mRS) score 5 vs 3, adjusted common OR (acOR) 0.31, 95% CI 0.16 to 0.61, P<0.01). Alcohol use (acOR 3.22, 95% CI 1.29 to 8.03, P=0.01) and an increased number of thrombectomy attempts (acOR 1.43, 95% CI 1.02 to 2.00, P=0.04) were independently associated with a heightened risk of PH. Conversely, local sedative anesthesia (acOR 0.10, 95% CI 0.01 to 0.84, P=0.03) was linked to a reduced risk of PH. CONCLUSIONS: In patients with large infarcts, PH is associated with a poorer functional prognosis after thrombectomy. Alcohol use and a higher number of thrombectomy attempts were positively associated with the occurrence of PH, whereas local sedative anesthesia was negatively correlated with its occurrence. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT04551664.