Successful reperfusion accompanied by symptomatic intracranial hemorrhage (sICH) versus unsuccessful reperfusion without sICH after endovascular stroke thrombectomy: a post-hoc analysis of two randomized trials

BACKGROUND: Functional outcomes in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) undergoing endovascular treatment (EVT) with successful reperfusion (expanded Thrombolysis In Cerebral Infarction (eTICI) 2b-3) complicated by symptomatic intracranial hemorrhage (sICH) were compared with patients with unsuccessful reperfusion (eTICI 0-2a) without sICH. METHODS: Patients enrolled in this post hoc analysis were from two Chinese multicenter, randomized controlled trials: the DEVT and the RESCUE BT registries. Patients with AIS who underwent EVT were categorized into two groups according to the state of reperfusion: eTICI 2b-3 with sICH and eTICI 0-2a without sICH. The primary outcome was the modified Rankin Scale (mRS) scores at 90 days. The safety outcomes included early neurological deterioration and 90-day mortality. RESULTS: 161 patients were included in this cohort analysis, among whom 71 experienced eTICI 2b-3 with sICH, and 90 had eTICI 0-2a without sICH. After adjusting for potential confounding factors, patients in the eTICI 2b-3 with sICH group had worse mRS at 90 days compared with those in the eTICI 0-2a without sICH group in the adjusted analysis (median 6 (IQR 4-6) vs median 4 (IQR 3-6); adjusted common OR 0.39, 95% CI 0.17 to 0.66). There were also higher rates of very poor outcome (mRS 5-6, 70.4% vs 42.2%; OR 2.90, 95% CI 1.38 to 6.11), mortality (66.2% vs 32.2%; OR 0.48, 95% CI 0.30 to 0.79), and early neurological deterioration (81.7% vs 40.0%; OR 0.16, 95% CI 0.07 to 0.35) in the eTICI 2b-3 with sICH group versus the eTICI 0-2a without sICH group. CONCLUSIONS: Successful reperfusion complicated by sICH after EVT was associated with worse outcomes and higher mortality than unsuccessful reperfusion without sICH. These findings emphasize the need for additional efforts in assessing and managing post-EVT-associated sICH to optimize treatment strategies and improve outcomes. TRIAL REGISTRATION NUMBER: Direct Endovascular Treatment for Large Vessel Occlusion Stroke; https://www.chictr.org.cn; ChiCTR-IOR-17013568.Intravenous Tirofiban Before Endovascular Thrombectomy for Acute Ischemic Stroke; https://www.chictr.org.cn; ChiCTR-INR-17014167.